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THE  TREATMENT  OF 

GONORRHEA 

AND  ITS  COMPLICATIONS 

IN  MEN  AND  WOMEN    , 

/' 

FOR  THE  GENERAL  PRACTITIONER 

BY 

WILLIAM  J.   ROBINSON,   M.D. 

Chief  of  the  Department  of  Genito- Urinary  Diseases   and  Dermatology,   Bronx 
Hospital   and   Dispensary ;    Editor  ..The   American   Journal  of   Urology,    Ven- 
ereal  and    Sexual  Diseases ;    Editor   of   The   Critic    and   Guide ;    Author   of 
Treatment  of  Sexual  Impotence  and  Other  Sexual  Disorders  in  Men  and 
Women;   Sexual  Problems  of  Today;  Never  Told  Tales;   Practical  Eu- 
genics, etc.    President  of  the  American  Society  of  Medical  Sociology, 
Ex-president    of    the     Berlin    Anglo-American    Medical    Society, 
Fellow   of    the    New    York   Academy   of    Medicine,    Member    of 
American    Medical    Editors'    Association,    American    Medical 
Association,    New    York    State    Medical    Society,    Interna- 
tionale    Gesellschaft     filr     Sexualforschung,     AmericazL 
Urological    Association,    etc.,    etc. 


SECOND  EDITION 


1917 
THE  CRITIC  AND  GUIDE  COMPANY 

12   MT.   MORRIS    PARK,  WEST 

NEW  YORK 


BY  THE  SAME  AUTHOR 


A  Practical  Treatise  on  the  Causes, 
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Impotence  and  other  Sexual  Dis- 
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Treatment  op  Gonorrhea  and  its 
Complications  in  Men  and  Women  .  3.00 

Sexual  Problems  of  To-day 2.00 

Sex  Knowledge  for  Men 2.00 

Sex  Knowledge  for  Women 1.50 

Woman:  Her  Sex  and  Love  Life 3.00 

Never  Told  Tales 1.00 

Stories  of  Love  and  Life 1.00 

Limitation  of  Offspring  by  the  Pre- 
vention OF  Conception 1.00 

Sex  Morality — Past,  Present  and 
Future 1.00 

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The'Critic  and  Guide 

Monthly:  $1.00  a  year;  Single  Copies,  20c. 

The  American  Journal  of  Urology 
AND  Sexology 

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Copyright,  1915, 
By  The  Critic  and  Guide  Co. 


fessor  Vr,  Heisser 

lehermer  MedlzlnaTrat 
FOrstenstrassa  HZ, 


i«*!fe»  JT4  ^  JL&^Jvli.  19I&^ 


Sehr  verehrtet"  lieber  Herr  Kollegel 

Geetern  kam  zu  gleicher  2elt  mit  Ihrem  Brief  dae  mir  geechenlctQ 
Buch  an.  Naturlich  habe  ich  mich   eofort  darauf  gesturzt  und  den  gan* 
zen  Abend  damit  zugebracht,    seinen  Inhalt  zu  etudieren.  Be  tut  mlr 
fast  leid.   dass  Sle  die  groese  Freundlichiceit  hatten,  mir  dae  Buch 
zu  dedizieren;  denn  eo  kbnnte  es  scheinen,  als  wenn  ich  dadurch  in 
neiner  Objektivitat  gestbrt  ware.  Dae  iet  aber  tatsachlich  nicht 
der  Fall  und  ich  kann  Ihnen  mit  gutem  Gewissen  versichern,   daes  ich 
mich  aufrichtig  iiber  die  von.  Ihnen  aufgeetellten  Prinzipien  und  I£e- 
tnoaen  gefreut  habe.  Ein  besonderes  Kompliment  muss  ich  Ihnen  noch 
fiir  die  Geschicklichkeit  machen,   wie  Sie  den  ganzen  Stoff  dargeetellt 
und  klargelegt  haben.  Beeonders  muse  ich  auch  darin  mit  Ihnen  uber* 
einstimmen,  wenn  Sie  gleich  Ihr  Buch  mit  der  Bemerkung  einleiten» 
dase  die  Gonorrhoebehandlung  nicht  Sache  von  Spezialisten  sein  diirfe, 
eondem  dass  alle  praktischen  Aerzte  in  der  Lage  sein  mussten,   diftse 
eo  ungemein  verbreitete  Volkskrankheit  zu  behandeln. 

Ganz  besonders  erstaunt  war  ich  iiber  die  AbbjLldung  meinee  Por- 
tl'aits;  wie  haben  Sie  das  zustanae  gebracht,    sich  die  Heproduktion 
jfiieser  mir  soeben  erst  im  Januar  geetifteten  Plakette  zu  verschaffen? 

Also  nochmals,   lieber  Herr  Kollege,  herzlichen  Dank.  Vielleicht 
darf  ich  auch  die  Bemerkung  hinzufiigen,   dass  gerade  in  diesen  Zeiten 
dee  Krieges   ich  es  ganz  besonders  freudig  empfand,   dass  ein  Nicht* 
Deutscher  mir  eine  solche  Ehrung  erwies. 

Hit  herzlichem  Gruss 

Ihr  Ihnen  eehr  ergeben^r 


J^tcJih^ 


TO 

PROFESSOR  ALBERT  NEISSER 

WHO  BY  HIS  DISCOVERY  OF 

THE  GONOCOCCUS,  THE  SPECIFIC  CAUSE  OF  GONORRHEA. 

HAS  RENDERED  AN  IMMORTAL  SERVICE 

TO  HUMANITY, 

THIS  BOOK  IS  RESPECTFULLY  DEDICATED 

BY  THE  AUTHOR 


PREFACE 

Some  specialists  in  venereal  diseases  say  that  all  patients 
afflicted  with  gonorrhea  should  go  to  a  specialist  for  treat- 
ment, and  not  to  a  general  practitioner.  They  say  that 
the  general  practitioner  is  not  competent  to  treat  gonor- 
rhea properly.  Whether  these  statements  are  made  by  the 
above  referred  to  specialists  from  purely  altruistic  motives, 
exclusively  out  of  consideration  for  the  patient's  welfare, 
is  not  a  question  that  needs  be  discussed  here.  Of  course 
the  specialist  would  be  financially  benefited;  there  is  no 
doubt  about  that;  but  the  patient  would  also  be  greatly 
benefited,  and  there  would  be  fewer  uncured  and  incurable 
cases  in  the  land.  Be  this  as  it  may,  granting  the  desira- 
bility of  having  every  case  of  gonorrhea  treated  by  a  spe- 
cialist, this  is  a  Utopian  desire;  a  hope  that  will  not  be 
realized  for  fifty  or  a  hundred  years  to  come.  There  are 
not  enough  gonorrhea  specialists  in  the  country  to  treat  all 
the  cases  of  gonorrhea.  We  are  told  that  next  to  measles 
gonorrhea  is  the  most  widespread  disease;  and  as  all  cases 
of  measles  could  not  be  treated  by  pediatrists,  so  all  cases 
of  gonorrhea  could  not  be  treated  by  urologists.  And  as- 
suming that  the  number  of  ''gonorrhea"  specialists  should 
become  adequate  to  the  task  of  handling  all  cases  of  gonor- 
rhea— supply  generally  follows  demand — it  would  be  abso- 
lutely impossible  for  everybody  to  patronize  a  specialist: 
their  economic  condition  would  not  permit  it.     We  forget 

that  medicine  is  greatly  influenced  by  the  financial  condi- 

7 


8  PREFACE 

tion  of  the  people.  And  medical  treatment  will  not  become 
ideal  until  a  radical  change  has  taken  place  in  our  social 
system.  And  as  this  is  going  to  take  some  time,  things  will 
run  the  way  they  have  been  running  for  another  century 
or  two,  and  ninety  per  cent,  of  all  men  unfortunate  enough 
to  contract  gonorrhea  will  continue  to  be  treated  by  the 
general  practitioner.  And  it  is  therefore  our  duty  to  do 
our  share  to  make  the  general  practitioner  as  competent 
as  possible. 

The  instruction  in  venereal  and  sexual  diseases  given  in 
our  medical  colleges  is  disgracefully  meager  and  is  re- 
sponsible for  the  inadequacy  of  the  average  general  prac- 
titioner in  the  treatment  of  these  diseases,  and  for  the  exist- 
ence of  the  quack.  A  good  plain  treatise  on  the  treatment 
of  gonorrhea  and  its  complications,  intended  specially  for 
the  general  practitioner,  seemed  to  the  author  as  well  as 
to  numerous  readers  of  his  books  and  journals,  a  desidera- 
tum. For  we  have  no  satisfactory  textbooks  on  gonorrhea. 
We  have  a  number  of  books  on  genito-urinary  surgery 
which  contain  chapters  on  gonorrhea,  we  have  a  number  of 
quiz  compends  on  venereal  diseases,  but  they  are  not  books 
which  answer  the  demands  of  the  general  practitioner. 
The  books  specially  devoted  to  the  treatment  of  gonorrhea, 
like  Wossidlo's,  are  too  technical  and  are  suitable  chiefly 
for  specialists.  The  best  book  on  the  treatment  of  gonor- 
rhea so  far  is  Luys'  ''Traite  de  la  Blenorrhagie, "  but  un- 
fortunately his  favorite  methods  of  treatment  are  urethro- 
vesical  irrigations  and  urethroscopy,  and  to  advise  the 
physician  to  treat  his  cases  of  gonorrhea  with  irrigations 
and  by  the  aid  of  the  urethroscope  is  to  do  the  physician 
and  his  patients  a  very  poor  service  indeed.     I  shudder  to 


PREFACE  9 

think  of  the  complications  and  of  the  number  of  incurable 
cases  that  would  result.  Even  in  skilled  hands  urethro- 
scopic  treatment  is  not  accomplishing  what  its  zealous 
advocates  claim  it  does;  in  unskilled  and  hurried  hands, 
as  must  be  those  of  the  physician  who  treats  all  other  ail- 
ments of  the  flesh,  it  would  lead  to  frequent  disaster.  The 
number  of  damaged  urethras  would  be  too  great  to  be 
counted.  Noli  nocere  is  the  first  requirement  of  any  treat- 
ment which  we  are  recommending  to  the  general  practi- 
tioner, and  this  motto  has  been  well  kept  in  mind  through- 
out the  book. 

The  style  of  the  book  is  the  plain,  non-stilted  style,  which 
the  author  has  used  in  his  ''Treatment  of  Sexual  Im- 
potence, ' '  which  he  uses  in  his  Critic  and  Guide  editorials, 
which  he  uses  in  his  ordinary  conversation.  Practically 
the  entire  book  has  been  dictated  right  from  the  head,  with- 
out referring  to  any  books.  It  was  considered  a  fairer  way 
to  present  the  present  day  status  of  the  successful  treat- 
ment of  gonorrhea  and  its  complications  than  by  merely 
rehashing  a  dozen  textbooks.  It  was  thought  that  what  a 
specialist  with  fair  abilities  and  a  good  memory,  who  has 
been  treating  venereal  diseases  daily  for  twenty  years, 
could  not  say  right  off,  without  reference  to  books,  regard- 
ing gonorrhea  or  any  of  its  complications,  was  not  worth 
knowing,  was  not  necessary  for  the  general  practitioner  to 
know.  Of  course  before  sending  the  typewritten  manu- 
script to  the  printer  I  gave  it  some  finishing  touches,  but 
the  book  is  distinctly  a  personal  book,  and  represents  how 
Dr.  Robinson  treats  gonorrhea  and  its  complications  and 
not  how  A.,  B.  and  C.  treat  them.  This  does  not  mean 
that  the  author  has  not  read  and  studied  the  various  text- 


10  PREFACE 

books  and  papers  on  gonorrhea;  on  the  contrary,  he  proh- 
ably  read  and  studied  every  one  of  any  significance ;  but  it 
does  mean  that  nothing  is  represented  in  this  book  that  has 
not  passed  through  the  crucible  of  his  judgment  and  ex- 
perience. 

The  author  is  convinced  that  by  following  the  teachings 
of  this  volume  the  general  practitioner  will  become  much 
more  successful  in  the  treatment  of  his  gonorrheal  patients 
than  he  has  been  in  the  past. 

W.  J.  R. 

12  Mt.  Morris  Park  West,  New  York. 


CONTENTS 


Peof.    Albert   Neissee Frontispiece 

chaptee  page 

Pbeface       7 

I    The  Extent  and  Seeiousness  of  Gonoeehea   .      .     13 
II    The  Classification  of  Ueetheal  Inflammations     18 

III  Gonobeheal  Ubetheitis  in  the  Male     .      .      .      .20 

IV  The  Geem  and  the  Diagnosis  of  Gonoeehea.        .     23 
V    The  Couese  and  Symptomatology  of  Acute  Gon- 
oeehea      29 

VI    Teeatment    of    Acute    Gonoeehea 35 

VII    Case  Eepoets 55 

VIII     Common  Bacteeial  Ubetheitis 61 

IX    Chanceoidal  Ubetheitis 65 

X    Syphilitic  oe  Chancre  Ubetheitis 67 

XI    Chemical  Ubetheitis »     .     ,     74 

XII    Peophylactic  Ubetheitis 86 

XIII  Tbaumatic  Ubetheitis 88 

XIV  Toxic  Ubetheitis 89 

XV     Ubetheitis  feom  Excess  and  Mastubbation     .      .91 

XVI     The     Widely     Vaeying     Conditions     Known     as 

Cheonic  Gonoeehea 93 

XVII     The  Teeatment  of   Cheonic   Gonoeehea     .      .      .97 
XVIII     The  Length  of  Time  Requieed  to  Cube  Cheonic 

Gonobeheal  Conditions 109 

XIX    The    Insteuments    Used    in    the    Treatment    of 

Gonoeehea 115 

XX    The  Abobtive  Treatment  of  Gonoeehea     .      .      .119 

XXI    The  Prevention  of  Gonoeehea 124 

XXII     The  Minoe  Complications  of  Gonoeehea   .      .      .   134 

XXIII  Acute  Pbostatitis 146 

XXIV  Cheonic  Prostatitis 154 


CONTENTS 


CHAPTER  PAGE 

XXV    Epididymitis 168 

XXVI    Seminal  Vesiculitis 183 

XXVII    Gonorrheal   Proctitis — ^Gonorrhea   of   the   Eec- 

TUM 187 

XXVIII    Gonorrheal      Stomatitis — Gonorrhea      op      the 

Mouth 189 

XXIX    Stricture 191 

XXX    Gonorrheal  Arthritis 202 

XXXI     Gonorrhea  vs.  Tobacco,  Alcohol,  and  Sexual  In- 
tercourse     .      .      .      ., 209 

XXXII    Gonorrhea  in  Women 218 

XXXIII  VULVO-VAGINITIS  IN   LITTLE  GiRLS 234 

XXXIV  Gonorrheal   Ophthalmia — Gonococcal   Infection 

OF   the   Eyeu     Ophthalmia   Neonatorum.     Oph- 
thalmia of  the  Newborn 243 

XXXV    Minor  Points 251 

XXXVI     Silver  Salts — Inorganic  and  Organic   ....  260 

XXXVII    Miscellaneous   Antiseptics   and   Astringents     .  267 

XXXVIII    Vegetable  Astringents 273 

XXXIX    Local  Anesthetics 274 

XL    Antigonorrheal  Remedies  for  Internal  Use  .      .277 

XLI     Urinary  Antiseptics 283 

XLII    Lubricants 288 

Formulary 291 

Index 309 


CHAPTER  I 
INTRODUCTION 

THE  EXTENT  AND  SERIOUSNESS  OF 
GONORRHEA 

I  suppose  it  would  be  the  appropriate  thing  to  start  this 
book  with  a  disquisition  upon  the  widespread  extent  of 
gonorrhea  and  all  the  terrible  ravages  that  it  works  in  the 
individual  and  in  the  race.  Gonorrhea  is  a  widespread 
disease  and  it  does  cause  great  ravages  in  the  individual 
and  in  the  race.  Nevertheless  neither  its  extent  nor  its 
seriousness  must  be  exaggerated.  The  writer  has  always 
had  a  great  aversion  to  lurid  exaggerations  of  any  kind: 
first,  because  an  exaggeration  is  an  untruth,  or  a  half-truth, 
which  Tennyson  declares  to  be  the  worst  of  lies;  and  sec- 
ond, an  exaggeration  usually  defeats  the  very  object  in  be- 
half of  which  it  is  propagated. 

The  exact  or  even  the  approximate  extent  of  the  preva- 
lence of  gonorrhea  no  living  person  knows.  All  figures  or 
statements  in  this  respect  are  pure  guesses  without  any 
solid  foundation.  We  all  go  by  impressions.  The  general 
practitioner  practicing  in  a  small  town,  who  frequently 
does  not  see  a  case  in  ten  years  (because  the  patients  go 
to  neighboring  large  cities  for  treatment  or  are  treated  by 
their  druggist  and  barber)  is  apt  to  minimize  the  extent 

of  venereal  disease.     The  specialist  who  treats  nothing  but 

13 


14      GONOERHEA  AND  ITS  COMPLICATIONS 

gonorrhea  is  apt  to  judge  of  all  humanity  by  his  patients, 
and  to  imagine  that  everybody  has  or  has  had  gonorrhea, 
forgetting  that  after  all  he  sees  only  a  very  small  percent- 
age of  the  population,  and  that  the  people  who  are  free 
from  the  disease  do  not  go  to  him  at  all  and  he  has  there- 
fore no  means  of  knowing  whether  they  have  or  have  not 
the  disease. 

I  have  always  been  fighting  against  the  specialist's  tend- 
ency to  exaggeration  and  strabismus,  and  I  will  say  right 
at  the  outset  that  the  statements  usually  made  that  eighty 
to  ninety  per  cent,  of  the  male  population  of  every  civil- 
ized country  have  or  have  had  gonorrhea  are  to  me  absurd. 
It  is  the  same  story  of  the  extreme  swinging  of  the  pendu- 
lum in  the  other  direction.  For  a  long  time  gonorrhea 
was  practically  disregarded  as  a  disease,  and  its  sequelae 
in  the  individual,  and  its  dangers  to  the  welfare  and  life 
of  the  future  wives,  were  not  even  dreamed  of.  Noeg- 
gerath  made  himself  immortal,  and  deserves  the  eternal 
gratitude  of  all  womanhood,  by  calling  the  attention  of 
the  profession  to  latent  gonorrhea  and  its  dangers.  But 
I  am  sure  that  his  statement  that  eighty  per  cent,  of  the 
male  population  has  gonorrhea,  that  ninety  per  cent,  of 
them  are  never  cured,  and  that  they  all  eventually  infect 
their  wives  was  a  wild  exaggeration. 

I  believe  that  if  we  say  that  twenty-five  per  cent,  of  the 
male  population  suffer  with  gonorrhea  at  one  time  or  an- 
other, we  would  rather  be  overstating  than  understating  the 
truth.  Of  course  its  prevalence  varies  in  different  strata 
of  society.  In  some  of  the  lower  strata  it  may  be  as  high 
as  one  hundred  per  cent.,  but  then  on  the  other  hand  there 
are  several  strata  of  society  in  which  it  does  not,  in  my 


SERIOUSNESS  OF  GONORRHEA  15 

opinion,  exist  to  a  greater  extent  than  five  or  ten  per  cent. 
As  to  the  curability  of  this  disease  I  also  disagree  with 
the  somber  estimates  of  the  pessimists.  Instead  of  ninety 
per  cent,  remaining  uncured  or  being  nncurable,  I  believe 
that  the  greatest  percentage  of  gonorrheas  end  in  a  prac- 
tical cure.  I  say  ''practical"  because  a  good  many  cases 
may  show  for  many  years  some  shreds  in  the  urine  or  a 
minute  droplet  of  discharge  and  still  be  practically  cured, 
that  is,  free  from  gonococci  and  non-dangerous  to  their 
partners.  Naturally,  I  also  disagree  with  the  statement 
as  to  the  frequency  with  which  wives  acquire  the  disease 
innocently  from  their  husbands.  According  to  the  state- 
ments of  some  of  our  zealous  friends  practically  every 
woman  who  marries  a  man  who  has  had  gonorrhea  acquires 
the  disease,  and  as  according  to  their  statements  eighty  or 
ninety  per  cent,  of  men  have  had  gonorrhea  at  one  time  or 
another  and  ninety  per  cent,  of  these  cases  remain  uncured, 
practically  every  married  woman  would  be  suffering  from 
gonorrhea.  Do  they  know  to  what  absurd  conclusions  this 
absurd  statement  leads?  The  race  would  have  become 
practically  extinct  if  the  statements  just  referred  to  were 
true.  Fortunately  they  are  not.  As  is  well  known,  Prof. 
Erb's  investigation  in  his  private  practice  led  him  to  the 
conclusion  that  only  four  per  cent,  of  women  who  married 
husbands  who  had  had  gonorrhea  contracted  the  disease. 
Allowing  for  the  fact  that  his  practice  was  among  the  well 
to  do,  who  can  afford  skillful,  prolonged  and  painstaking 
treatment,  we  would  be  justified  in  stating  that  about  ten 
per  cent,  of  married  women  acquire  the  disease  innocently, 
a  high  enough  figure  as  it  is,  enough  to  terrify  us  without 
any  exaggerations!     Exaggeration  and  painting  in  lurid 


16       GONORRHEA  AND  ITS  COIVIPLICATIONS 

colors  may  be  permissible  for  propaganda  purposes,  but 
they  should  be  frowned  upon  by  scientists  whose  only  func- 
tion is  to  tell  the  truth. 

SERIOUSNESS  OP   GONORRHEA 

Gonorrhea  is  a  serious  disease,  serious  to  the  individual 
male,  potentially  serious  to  his  wife  and  to  his  children. 
But  even  here  we  must  not  exaggerate.  One  writer  says 
we  must  tell  our  young  men  that  gonorrhea  may  end  in 
death.  But  so  may  measles,  so  may  a  pinprick,  so  may  the 
paring  of  a  corn  or  the  extraction  of  a  tooth.  It  is  all  a 
matter  of  the  frequency  of  such  an  eventuality.  It  is  true 
that  gonorrhea  may  end  in  an  endocarditis  or  a  general 
septicemia  leading  to  death,  but  these  results  are  extremely 
rare,  and  we  gain  nothing  by  using  these  possible  but  ex- 
tremely rare  sequelss  as  specters  to  frighten  our  young 
men.  In  the  vast  majority  of  cases  gonorrhea  is  a  per- 
fectly curable  disease,  leaving  few  or  no  sequelge. 

Gonorrhea  is  a  serious  and  dangerous  disease,  but  its 
seriousness  and  dangerousness  do  not  reside  in  the  gonor- 
rhea per  se,  but  in  our  social-economic  conditions,  which 
do  not  permit  the  individual  the  proper  rest  and  the  proper 
treatment.  If  our  patients  attacked  with  gonorrhea  could 
at  once  obtain  the  same  care  and  treatment  as  do  patients 
attacked  with  typhoid  fever  or  pneumonia,  ninety  per  cent, 
of  them  would  be  perfectly  well  by  the  end  of  two  or  three 
weeks. 

But  because  gonorrhea  is  a  ''shameful"  disease,  because 
the  young  man  must  hide  its  existence  from  his  parents, 
because  there  are  no  hospitals  which  accept  venereal  pa- 
tients, because  the  patient  must  keep  on  working,  perhaps 


SERIOUSNESS  OF  GONORRHEA  17 

running  up  and  down  stairs  and  lifting  heavy  weights,  be- 
cause he  is  unable  to  go  to  skillful  specialists,  but  is  obliged 
to  treat  himself  with  nostrums  or  be  treated  by  the  hurried 
and  not  always  competent  general  practitioner,  or  in  the 
frequently  worse  than  useless  dispensaries ;  because  of  these 
things  gonorrhea  becomes  in  many  cases  such  a  serious  dis- 
ease, dangerous  to  the  individual  himself  (arthritis,  endo- 
carditis, etc.),  to  his  wife  (endometritis,  salpingitis,  ovari- 
tis), to  the  child  (ophthalmia  neonatorum)  and  by  his  be- 
coming sterile  or  by  rendering  the  wife  sterile,  to  the  race. 
To  emphasize  and  to  recapitulate:  Skillfully  treated 
from  the  beginning,  under  proper  hygienic  and  dietetic 
conditions,  gonorrhea  is  a  benign  affection;  neglected  or 
maltreated  gonorrhea  becomes  an  intensely  dangerous  dis- 
ease. Which  again  brings  us  to  the  point  emphasized  by 
the  author  so  many  times,  that  if  we  wish  to  be  successful 
in  the  treatment  of  our  patients  we  must  demand  an  im- 
provement or  a  radical  change  in  the  social-economic  condi- 
tions of  the  people. 


CHAPTER  II 

THE  CLASSIFICATION  OF  URETHRAL 
INFLAMMATIONS 

Urethritis  is  an  inflammation  of  the  urethra  accompanied 
by  pain,  swelling  and  discharge.  Not  all  urethral  dis- 
charges and  inflammations  are  due  to  the  gonococcus.  Of 
course  gonorrhea  is  so  much  more  frequent  and  serious  that 
it  overshadows  all  other  urethral  troubles.  Nevertheless 
if  we  wish  to  avoid  blunders,  blunders  which  may  prove 
extremely  serious  to  the  patient,  we  must  bear  in  mind 
that  a  discharge  from  the  urethra  may  be  of  other  than 
gonococcal  origin,  and  I  therefore  give  at  the  outset  a 
classification  of  urethral  inflammations.  Bearing  this  clas- 
sification in  mind  may  help  one  to  avoid  gross  errors  in 
diagnosis. 

We  divide  them  first  into  two  large  classes : 

I.  Bacterial. 

II.  Non-bacterial. 

In  the  bacterial  class  we  have  the  following  varieties: 

1.  Gonococcal  or  Gonorrheal; 

2.  Common  or  simple  bacterial; 

3.  Chancroidal; 

4.  Syphilitic; 

5.  Tubercular; 

6.  Neoplastic  (?) 

The  non-bacterial  or  aseptic  urethrites  may  be  classified 

as  follows: 

18 


CLASSIFICATION  19 

7.  Chemical; 

8.  Traumatic; 

9.  Toxic; 

10.  Diathesic. 

To  class  urethrorrliea  among  the  urethrites  is  incorrect, 
for  urethrorrhea  can  hardly  be  considered  an  inflamma- 
tion of  the  urethra.  Still  more  incorrect  and  utterly  with- 
out excuse  is  to  class  prostatorrhea  and  so-called  sperma- 
torrhea among  the  urethrites. 


CHAPTER  III 
GONORRHEAL  URETHRITIS  IN  THE  MALE 

Gonorrhea  or  gonorrheal  urethritis  is  an  inflammation  of 
the  urethra  caused  by  a  germ  which  was  discovered  by 
Neisser  in  1879  and  named  by  him  the  gonococcus,  or  the 
gonococcus  of  Neisser. 

Taking  the  word  gonorrhea  in  its  pre-Neisserian  sense, 
as  synonymous  with  urethral  discharge,  the  disease  is  one 
of  the  oldest  known.  It  is  mentioned  in  the  Bible,  and  it 
has  been  described  by  Greek  and  Roman  writers.  Of 
course  we  have  no  means  of  knowing  whether  the  urethral 
discharge  spoken  of  by  the  ancients  was  specific  in  char- 
acter and  due  to  the  gonococcus,  or  whether  it  was  due  to 
some  other  germ,  or  altogether  non-bacterial;  but  we  are 
justified  in  assuming  that  at  that  time,  the  same  as  now, 
most  of  the  cases  were  due  to  the  gonococcus.  The  de- 
scription given  by  the  ancients  tallies  very  well  with  our 
gonorrhea. 

The  etymology  of  the  word  gonorrhea  is  barbarous  in  the 
extreme,  if  we  consider  its  significance.  Literally  it  means 
a  running  of  semen,  from :  gonos=sem.en  and  rheo=l  run. 
The  ancients  thought  that  the  urethral  discharge  was  due 
to  running  out  of  spoiled,  poisoned  semen.  We  know  bet- 
ter, but  all  attempts  to  change  the  word  have  proved  and 
will  prove  fruitless.  It  is  difficult  or  impossible  to  change 
an  incorrect  but  thoroughly  established  word  for  one  sci- 

20 


GONORRHEAL  URETHRITIS  21 

entifically  correct.  Nor  is  it  necessary.  Language  was 
made  for  man,  not  man  for  language,  and  as  long  as  the 
word  stands  for  something  definite  and  gives  rise  to  no  con- 
fusion in  anybody's  mind,  it  is  a  good  word,  and  all  at- 
tempts to  change  it  must  prove  quixotic.  The  name  which 
Neisser  gave  to  the  specific  germ  of  gonorrhea  is  not  any 
better,  for  what  does  gonococcus  mean?  It  means  semen- 
coccus,  which  is  of  course  absurd.  But  we  know  what  it 
stands  for,  and  it  is  useless  to  attempt  to  change  it. 
*' Gonorrheal  urethritis"  or  '' gonococcal  urethritis"  are 
not  much  better,  nor  are  the  terms  blenorrhea  and  blenor- 
rhagia,  used  in  Germany  and  France  respectively,  a  great 
improvement.  We  will  therefore  adhere  to  the  old  term 
gonorrhea,  it  being  understood  that  when  we  use  the  term 
without  any  other  qualification,  we  refer  to  an  inflamma- 
tion of  the  urethra  caused  by  the  diplococcus  of  Neisser. 
When  speaking  of  the  complications  we  will  use  gonorrheal 
prostatitis,  gonorrheal  epididymitis,  gonorrheal  vesiculitis, 
etc. 

The  infection  takes  place  almost  exclusively  during  sexual 
intercourse.  But  note  that  I  said  almost.  1  do  not  at  all 
deny  the  possibility  of  non-venereal  infection,  from  soiled 
linen  or  infected  instruments;  and  it  will  not  do  to  sneer 
at  the  possibility  of  infection  from  a  bathtub  or  the  seat 
of  a  water-closet.  In  a  Berlin  clinic  I  watched  an  acutely 
gonorrheal  patient  go  into  a  privy.  When  he  got  up  there 
was  about  half  a  teaspoonful  of  thick  creamy  pus  on  the 
seat,  at  the  point  touched  by  the  meatus.  A  person  sitting 
down  on  that  seat  within  an  hour  or  two  would  be  very  apt 
to  get  some  of  the  pus  transferred  to  his  urethra  and  to 
develop  a  gonorrheal  urethritis.     That  gonorrheal  ^mlvo- 


22       GONORRHEA  AND  ITS  COMPLICATIONS 

vaginitis  in  little  girls — which  however  seems  to  be  of  a 
different  character  from  the  gonorrhea  of  adults — may  and 
often  does  assume  the  character  of  an  epidemic,  the  infec- 
tion being  carried  by  soiled  linen,  by  the  nurses,  etc.,  and 
is  often  contracted  in  the  water-closets  of  the  school,  is  of 
course  well  known. 

But  the  histories  of  my  patients  alone  would  be  sufficient 
to  make  me  refrain  from  being  dogmatic  about  the  non- 
possibility  of  extra-venereal  gonorrheal  infection.  As  I 
stated  elsewhere,  I  know  that  my  patients  do  not  lie  to  me ; 
they  certainly  do  not  all  lie.  They  know  that  I  am  not  a 
hypocrite,  that  I  am  not  going  to  pass  sanctimonious  judg- 
ment upon  them,  and  they  have  no  reason  whatever  to  lie 
about  the  manner  in  which  they  acquired  their  gonorrhea  or 
syphilis.  They  also  fear  that  deceiving  the  doctor  about 
any  detail  in  their  history  may  lead  to  different  treatment 
and  that  thus  they  may  not  be  benefited  or  may  even  be 
injured.  When,  therefore,  an  intelligent  patient  assures 
me  that  he  had  never  had  sexual  intercourse,  or  had  not 
had  any  for  several  months,  that  he  knows  no  cause  for  his 
urethral  discharge,  which  shows  the  presence  of  gonococci, 
except  perhaps  that  he  visited  a  toilet  in  a  railway  or  sub- 
way station,  or  slept  in  a  second  rate  hotel  in  Avhich  the 
bedding  was  not  of  immaculate  purity,  I  see  no  reason 
whatever  for  doubting  his — or  her— story. 

Of  course  the  cases  of  extra-venereal  gonorrheal  infec- 
tion are  few  in  number  in  comparison  with  those  contracted 
during  sexual  intercourse;  but  it  is  important  that  their 
possibility  be  not  denied  altogether.  Admitting  their  pos- 
sibility may  prevent  unjust  accusations,  and  occasionally 
the  breaking  up  of  a  home. 


CHAPTER  IV 

THE  GERM  AND  THE  DIAGNOSIS  OF 
GONORRHEA 

The  gonocoeeus,  the  little  germ  or  micro-organism  which 
is  responsible  for  so  much  human  misery,  is  exclusively  a 
human  parasite.  It  can  live  and  thrive  in  the  human  body 
only.  All  attempts  to  inoculate  the  gonocoeeus  in  any  ani- 
mal have  failed ;  no  animal  can  be  infected  with  gonorrhea. 
Perhaps  it  was  sent  to  the  human  race  to  keep  it  from 
promiscuity.  It  is  about  half  the  size  of  a  red  blood  cor- 
puscle, about  1-50  [X  in  length  and  0.7  fi  in  width.  It  is  a 
diplococcus,  that  is,  it  occurs  always  in  twos  or  in  multiples 
of  twos.  This  is  due  to  its  method  of,  division.  Under  the 
microscope  in  good  preparations  they  appear  like  a  coffee- 
bean  which  has  been  opened  and  laid  out  flat.  They  are 
found  both  in  the  cells  and  outside  of  the  cells,  and  we 
speak  of  them  as  extra-cellular  and  intracellular,  but  the 
intracellular  position  is  the  characteristic  one,  and  a  micro- 
scopic specimen  which  contains  many  extra-cellular  but 
no  intracellular  cocci  would  not  be  typical  and  would  not 
give  us  the  right  to  make  the  diagnosis  gonorrhea. 

It  stains  readily  with  the  ordinary  basic  anilin  dyes,  such 

as  methylene  blue,  bismarck  brown,  methyl  violet,  saffronin, 

fuchsin,  etc.,  and  if  the  smear  is  properly  prepared  can  be 

easily  identified  under  the  microscope.     Numerous  stains 

have  been  invented,  gi^dng  us  very  pretty  microscopic  speci- 

23 


24       GONORRHEA  AND  ITS  COMPLICATIONS 

mens,  but  the  general  practitioner  needs  know  but  one  or 
at  most  two  stains,  and  if  he  only  learns  to  apply  them 
properly  he  will  get  for  every  practical  purpose  results  as 
good  as  does  the  expert  bacteriologist  with  the  very  com- 
plicated and  refined  stains.  But  the  smear  must  be  pre- 
pared properly. 

HOV^   TO  PREPARE  A  PROPER   SMEAR 

One  of  the  common  errors  to  which  the  beginner  is  liable 
is  to  make  the  smear  too  thick.  This  is  an  error  which  must 
be  guarded  against ;  the  thinner  the  layer  of  pus  the  better. 
Take  a  clean  glass  slide,  take  a  wooden  stick  or  a  toothpick 
and  wind  around  it  a  small  wisp  of  cotton,  dip  the  cotton 
in  sterile  water  and  shake  off  the  excess.  If  the  pus  is 
gushing  from  the  urethra,  wipe  off  the  meatus  with  some 
cotton  or  wash  it  off  with  sterile  water  to  prevent  con- 
tamination with  germs  which  may  abound  on  the  glans  and 
meatus.  Insert  the  cotton  carrier  into  the  fossa  navicu- 
laris,  and  with  the  pus  thus  obtained  make  several  narrow 
smears  over  the  glass  slide.  This  distributes  the  pus  very 
evenly  and  very  thinly,  and  for  this  reason  I  prefer  this 
method  to  the  platinum  loop  or  to  squeezing  the  pus  be- 
tween two  slides.  Where  the  pus  is  very  scanty  and  we 
have  to  go  deep  into  the  urethra  to  obtain  some,  there  the 
platinum  loop  may  be  used.  We  then  allow  the  thin  layer 
of  pus  to  dry  on  the  slide,  which  takes  a  minute  or  two, 
then  pass  it  three  times  lightly  and  quickly  over  the  flame 
of  an  alcohol  lamp  or  Bunsen  burner.  This  fixes  the 
preparation.  With  a  glass  dropper  we  then  drop  one  or 
two  or  three  drops  of  Loeffler's  solution  of  methylene  blue, 
allow  it  to  remain  two  minutes,  then  wash  off  in  running 


DIAGNOSIS  OF  GONORRHEA  25 

water.  We  then  dry  it  with  blotting  paper  (this  step  may 
be  left  off)  put  on  a  cover  glass,  put  a  drop  of  cedar  oil  in 
the  center  of  the  cover  glass,  and  examine  with  a  1-12  oil 
immersion  lens.  And  if  the  typical  diplococci  are  present, 
the  patient  presents  the  ordinary  history  and  symptoma- 
tology of  gonorrhea,  the  diagnosis  is  settled  and  no  further 
investigations  are  necessary. 

We  hear  of  the  danger  of  making  a  diagnosis  of  gonor- 
rhea by  the  microscope  alone,  of  the  possibility  of  confus- 
ing gonococci  with  the  pseudo-gonococci  and  the  micrococ- 
cus catarrhalis,  etc.,  but  these  are  all  academic  points,  and 
in  the  vastest  majority  of  cases  the  general  practitioner 
will  not  be  confronted  with  them.  The  general  practi- 
tioner can  never  hope  to  become  an  expert  bacteriologist, 
and  where  a  medico-legal  question  comes  up,  or  where  a 
man  wants  a  final  authoritative  judgment  as  to  his  com- 
plete cure  and  permissibility  to  enter  matrimony,  the  de- 
cision will  have  to  be  put  into  the  hands  of  a  specialist. 

In  the  vast  majority  of  cases  the  patient  comes  to  the 
doctor  with  unmistakable  signs  and  symptoms  of  urethri- 
tis. The  decision  to  be  made  then  is  only :  Is  it  a  gonor- 
rheal or  a  non-gonorrheal  urethritis? — and  to  decide  that 
question  the  methylene  blue  test  is  sufficient  in  the  vast 
majority  of  cases. 

It  occasionally  happens  that  either  because  the  gonococci 
have  undergone  a  degenerative  morphologic  change,  or  on 
account  of  contamination  with  other  germs,  it  is  impossible 
to  decide  definitely  whether  the  cocci  that  we  see  in  the 
field  are  gonococci  or  not.  In  such  a  case  we  must  use  the 
well  known  Gram  stain,  which  was  elaborated  for  us  by 
Roux  of  the  Pasteur  Institute. 


26       GONORRHEA  AND  ITS  COMPLICATIONS 

Germs  can  be  divided,  according  to  the  manner  in  which 
they  behave  toward  the  Gram  stain,  into  Gram-positive  and 
Gram-negative.  The  Gram-positive  take  the  Gram  stain 
and  are  stained  by  it  a  deep  blue-black.  The  Gram-nega- 
tive do  not  take  the  Gram  stain,  or  if  they  have  been  stained 
by  some  of  the  anilin  dyes  are  decolorized  by  the  procedure 
involved  in  making  the  Gram  test.  The  gonococcus  is  a 
Gram-negative  germ.  So  then  if  we  stain  a  specimen  with 
one  of  the  anilin  dyes,  examine  it  under  the  microscope 
and  see  clearly  a  number  of  cocci,  then  we  subject  the 
specimen  to  the  Gram  stain,  and  examine  again  the  speci- 
men under  the  microscope  and  find  that  the  cocci  have  be- 
come decolorized,  we  know  that  we  have  to  deal  with  gon~ 
ococci,  while  if  the  cocci  which  we  saw  before  remain 
stained  they  are  not  gonococci. 

The  Gram  test  is  performed  as  follows.  Prepare  and  fix 
the  slide  as  before,  pour  over  it  some  anilin-water-gentian- 
violet  dye  and  leave  on  for  two  minutes,  then  shake  off  the 
excess  and  dip  in  Lugol's  solution.  Now  dip  the  slide  in 
absolute  alcohol.  This  decolorizes  the  gonococci.  If  we 
examine  the  specimen  at  this  stage  we  will  find  that  the 
Gram-positive  cocci,  if  there  are  any  there,  are  of  a  blue- 
black  color,  while  the  gonococci  have  disappeared  from  the 
field,  so  to  say,  for  being  unstained  they  can  be  seen  but 
with  difficulty.  If  we  wish,  however,  we  can  use  a  double 
stain,  and  after  removing  the  slide  from  the  absolute  alco- 
hol we  dip  it  in  or  pour  over  it  some  bismarck  brown  solu- 
tion. Examining  the  specimen  then,  the  gonococci  will  ap- 
pear of  a  light  brownish  color,  while  the  pseudo-gonococci 
will  be  blue-black. 


DIAGNOSIS  OF  GONORRHEA  27 

CULTURES 

The  gonococcus  is  a  difficult  germ  to  cultivate.  It  does 
not  grow  on  ordinary  culture  media,  such  as  agar-agar, 
glycerin-gelatin,  etc.  The  medium  must  contain  some 
human  serum,  blood  serum,  ascitic  fluid,  etc.  The  general 
practitioner  cannot  possess  the  facilities  nor  can  he  acquire 
the  skill  necessary  for  making  cultures  of  gonococci.  Nor 
is  the  procedure  of  very  much  use.  We  often  hear  it 
stated  by  some  genito-urinary  specialists  that  we  cannot 
make  a  diagnosis  of  gonorrhea  from  microscopic  examina- 
tions alone,  that  we  must  always  make  a  culture.  This  is 
a  fatuous  statement,  often  made  I  fear  for  the  sake  of  per- 
sonal aggrandizement.  And  again,  first  of  all,  even  a  prop- 
erly made  culture  in  the  hands  of  an  expert  bacteriologist 
is  not  absolutely  conclusive  evidence,  errors  can  occur  even 
there.  Second,  the  cultures  as  made  by  the  average  labora- 
tory are  very  often  worse  than  useless,  because  misleading. 
Third,  the  cases  where  with  the  history,  clinical  symptoms, 
and  bacteriological  findings  we  are  unable  to  make  our 
diagnosis,  are  so  rare  as  to  be  negligible.  In  over  twenty 
years'  practice,  treating  patients  with  I  believe  a  fair  de- 
gree of  intelligence  and  success,  I  have  not  found  it  neces- 
sary once  to  have  recourse  to  a  culture.  Fourth,  it  is  not 
so  important.  I  mean  just  what  I  say,  that  the  differen- 
tial diagnosis  between  the  gonococcus  and  some  other  coccus 
is  not  such  a  life  and  death  matter  as  some  of  our  con- 
freres would  unwittingly  make  us  believe.  One  would 
think  that  the  gonococcus  is  the  only  deadly  bacillus  and 
that  if  the  symptoms  of  which  the  patient  complains  are 
due  to  some  other  germ  the  case  is  of  no  importance.     This 


28       GONORRHEA  AND  ITS  COMPLICATIONS 

is  far  from  being  true.  Other  bacteria  flourishing  in  the 
urethra  may  give  rise  to  as  much  trouble  as  the  gonococcus. 
We  can  have  very  severe  epididymitis,  prostatitis,  or  vesic- 
ulitis from  the  coli  bacillus,  staphylococcus,  etc.;  and 
cystitis,  pyelitis,  and  pyelonephritis  are  much  more  apt  to 
follow  infection  by  other  germs  than  they  are  to  be  the  re- 
sult of  gonococcal  infection.  So  what's  the  difference? 
Whether  the  urethritis  and  its  various  complications  are 
due  to  the  gonococcus  or  to  other  germs  they  have  to  be 
treated,  and  the  treatment  is  practically  the  same  what- 
ever the  infecting  agent  is.  Fifth,  the  complement  fixa- 
tion test  is  more  reliable,  gives  us  more  information,  takes 
less  time  and  is  less  troublesome  to  perform.  The  comple- 
ment fixation  test,  similar  to  the  Wassermann  test  for 
syphilis,  is  now  performed  by  all  serologic  laboratories.  All 
the  general  practitioner  has  to  do  is  to  draw  a  dram  or 
two  of  blood  from  one  of  the  veins  in  the  elbow,  put  it  in 
a  sterilized  bottle  and  send  it  to  the  laboratory. 


CHAPTER  V 

THE  COURSE  AND  SYMPTOMATOLOGY  OF 
ACUTE  GONORRHEA 

The  course  of  acute  gonorrhea,  or  more  specifically  speak- 
ing, acute  gonorrheal  urethritis  in  the  male  may  be  divided 
into  five  stages:  (1)  the  stage  of  incubation,  (2)  pro- 
dromal, (3)  acute  or  ascending,  (4)  subacute  or  stationary, 
and  (5)  declining  or  subsiding  stage. 

The  stage  of  incubation  is  the  period  from  the  moment 
of  infection  to  the  moment  of  the  appearance  of  subjective 
symptoms.  When  the  gonococci  get  into  the  urethra  they 
do  not  cause  symptoms  at  once  (it  would  be  better  if  they 
did) .  It  takes  them  some  time  to ' '  settle  down, ' '  to  increase 
and  multiply,  to  get  into  and  between  the  epithelial  cells 
of  the  urethral  mucous  membrane,  and  cause  inflam- 
matory symptoms.  The  time  required  for  this  develop- 
ment, in  other  words  the  length  of  the  incubation  stage, 
varies  in  different  cases;  but  the  usual  length  is  between 
three  to  five  days.  In  other  words  it  takes  three  to  five  days 
from  the  moment  of  an  infectious  intercourse  until  the 
patient  becomes  aware  that  there  is  anything  the  matter 
with  him.  During  that  time  the  patient  is  perfectly  well. 
The  incubation  stage  may  only  last  twelve  hours,  and  may 
last  as  long  as  two  weeks;  but  this  is  exceptional.  The 
shortest  incubation  stage  in  my  personal  experience  was 
twenty-four    hours,    the    longest    twelve    days.     The    re- 

29 


30       GONORRHEA  AND  ITS  COMPLICATIONS 

ported  incubation  stages  of  four  to  eight  weeks  may  be 
taken  with  a  grain  of  salt.  Or  perhaps  it  is  possible  that 
the  gonococci  are  deposited  on  the  glans  under  the  prepuce, 
and  only  later  on,  after  several  weeks,  become  accidentally 
transported  to  the  urethra.  At  any  rate,  it  is  well  to  re- 
•member  that  in  the  vast  majority  of  cases  of  gonorrhea 
the  incubation  stage  lasts  from  three  to  five  days;  the  less 
common,  but  still  not  excessively  rare,  limits  are:  one  to 
seven  days. 

At  the  end  of  this  period  the  patient  becomes  aware  of 
some  peculiar  sensation  in  the  urethra — the  prodromal 
stage  commences.  The  patient  feels  a  little  tickling  or 
burning  in  the  urethra,  particularly  in  the  neighborhood 
of  the  fossa  navicularis — where  the  gonococci  generally 
settle  down.  If  he  looks  at  his  penis  he  finds  that  the  lips 
of  the  meatus  are  a  little  puffed,  edematous  and  red ;  they 
may  be  slightly  stuck  together;  but  there  is  no  discharge. 
If  the  patient  is  told  to  urinate,  the  urine  is  found  clear. 
This  stage  lasts  from  about  twelve  to  forty-eight  hours,  and 
the  acute  stage  is  before  us.  Then  the  most  prominent 
symptom  of  gonorrhea,  the  discharge — which  the  patient  has 
been  fearing  and  hoping  against  hope  would  not  come — 
makes  its  appearance.  At  first  it  is  scanty,  and  almost  a 
pure  white ;  gradually  it  increases  in  amount,  becomes  very 
profuse,  running  almost  continually  and  bathing  the  glans 
and  prepuce,  and  assumes  a  yellowish,  then  greenish  yellow 
color.  The  symptoms  keep  getting  worse  (unless  checked 
by  rational  treatment).  The  lips  of  the  meatus  may  be 
slightly  eroded;  the  glans  and  the  prepuce  are  somewhat 
red  and  swollen ;  the  entire  urethra,  particularly  the  fossa 
navicularis,  is  sensitive  and  painful ;  the  act  of  micturition 


COURSE  AND  SYMPTOMATOLOGY  31 

is  painful,  the  urine  causing  a  burning  sensation,  so  that 
the  patient  abstains  from  urinating  as  long  as  possible; 
the  entire  penis  may  feel  hot  and  turgid,  and  painful  erec- 
tions are  not  uncommon.  If  the  patient  urinates  in  two 
glasses,  the  first  one  is  very  turbid,  but  the  second  one  is 
clear.  This  acute  or  ascending  stage  lasts  from  seven  to 
ten  days,  when  a  stationary  period  lasting  from  one  to  two 
weeks  supervenes.  The  discharge  is  less  profuse,  urination 
is  less  painful,  but  things  remain  in  statu  quo,  without 
much  change  until  the  last,  the  declining  stage.  In  this 
stage  the  symptoms  abate  rapidly,  the  discharge  diminishes 
gradually,  until  there  is  but  a  scanty  drop,  and  this  also 
gradually  disappears,  until  in  two  or  three  weeks — ^that  is 
at  the  end  of  five  or  six  weeks  from  the  appearance  of  the 
first  symptoms,  the  gonorrhea  is  completely  cured.  There 
is  no  discharge,  the  urine  is  perfectly  clear,  and  no  gono- 
cocci  can  be  found. 

The  above  is  a  faithful  description  of  an  average  case  of 
acute  anterior  urethritis;  but  where  the  inflammation  ex- 
tends to  the  posterior  urethra,  which  is  the  case  in  the  vast 
majority  of  instances,  two  other  symptoms  become  promi- 
nent and  cause  great  annoyance.  These  two  symptoms  are 
strangury,  a  strong  desire  to  urinate  every  few  minutes 
during  the  day  (and  several  times  during  the  night),  and 
severe  pain  at  the  end  of  micturition.  While  in  the  course 
of  anterior  urethritis  the  act  of  micturition  causes  pain, 
it  is  not  so  intense,  and  is  more  of  a  scalding  or  burning  sen- 
sation; here  the  pain,  particularly  while  passing  the  last 
few  drops,  is  very  intense ;  the  patient  often  grits  his  teeth, 
and  a  cold  sweat  bathes  his  forehead  and  body. 

If  the  gonorrheal  inflammation  could  be  kept  limited  to 


32       GONORRHEA  AND  ITS  COMPLICATIONS 

the  anterior  urethra,  gonorrhea  would  be  indeed  if  not  a 
trifling,  at  least  not  a  very  serious  disease.  It  is  the  ad- 
vancing of  the  inflammation  to  the  posterior  urethra  that 
renders  gonorrhea  one  of  the  most  annoying  diseases  we 
have  to  deal  with.  For  it  is  through  the  inflammation  of 
the  posterior  urethra  that  we  get  prostatitis,  vesiculitis, 
deferentitis,  epididymitis  and  cystitis,  and  the  rarer  but 
more  serious  renal,  arthritic  and  cardiac  complications. 

I  gave  the  symptomatology  of  a  case  of  gonorrheal  ure- 
thritis of  average  severity.  There  are  various  gradations 
however,  from  extremely  acute  or  superacute  to  very  mild 
or  subacute. 

SUPERACUTE  GONORRHEAL  URETHRITIS 

"Whether  due  to  a  special  virulence  of  the  gonococci,  to 
an  excessive  dose  of  them,  to  a  special  susceptibility  of  the 
patient,  or  to  the  fact  that  he  had  indulged  in  an  alcoholic 
debauch  prior  to  the  sexual  one,  some  cases  of  gonorrhea 
pursue  a  violent  stormy  character  from  the  very  beginning. 
After  a  short  incubation  stage,  with  practically  no  pro- 
dromal symptoms,  there  starts  a  profuse  greenish  discharge, 
often  mixed  with  blood,  the  entire  penis  is  hot  and  swollen, 
the  meatus  is  excoriated  and  everted,  the  prepuce  is  in- 
flamed and  becomes  either  phymotic  or  paraphymotic,  the 
acid  discharge  corrodes  the  glans,  which  becomes  balanitic, 
urination  is  excruciatingly  painful,  the  act  of  urination 
being  followed  by  a  few  drops  of  blood,  there  are  painful 
erections  and  chordee,  and  there  are  almost  nightly  pollu- 
tions, which  are  also  excruciatingly  painful,  the  semen 
being  mixed  with  pus  and  blood.  Besides  these  local  symp- 
toms, the  patient's  general  condition  is  decidedly  affected. 


COURSE  AND  SYMPTOMATOLOGY  33 

There  may  be  fever,  there  is  a  general  feeling  of  malaise, 
headache,  chilliness ;  there  is  loss  of  appetite  and  the  sleep 
is  disturbed.  "Whether  due  to  the  loss  of  appetite  and 
sleep  or  to  action  of  the  gonorrheal  toxin  circulating  in 
the  blood,  the  patient  may  lose  several  pounds  of  flesh  and 
become  pronouncedly  anemic  in  a  very  short  time. 

Strange  to  say,  these  violent,  superacute  cases,  if  serious 
complications  have  not  set  in,  often  end  rapidly  in  perfect 
recoveries.  How  to  account  for  it?  I  account  for  it  by 
the  fact  that  people  having  this  kind  of  gonorrhea  do  not 
temporize  and  do  not  go  about  their  business.  Their  in- 
tense suffering  forces  them  to  stay  at  home  and  to  call  in 
at  once  the  aid  of  a  competent  physician. 

SUBACUTE  OR  MILD  GONORRHEAL  URETHRITIS 

The  opposite  of  the  picture  presented  by  superacute 
urethritis  is  presented  by  this  variety.  A  few  days  after 
intercourse  the  patient  notices  a  little  tickling  or  burning  in 
the  urethra,  or  these  symptoms  may  be  altogether  absent. 
Then  he  notices  a  little  discliarge ;  it  is  slight  in  amount,  and 
the  act  of  urination  causes  him  no  trouble  whatever;  nor 
does  he  suffer  from  erections,  chordee,  etc.  In  fact  he  says 
that  but  for  the  slight  discharge  he  would  not  know  that 
there  was  anything  the  matter  with  him.  These  are  the 
mild  cases  which  the  patient  often  neglects,  with  the  result 
that  they  often  terminate  in  chronic  gonorrhea  or  gleet,  or 
through  some  imprudence  on  the  part  of  the  patient — he 
does  not  think  that  he  is  sick  enough  to  follow  a  strict 
regime — they  become  converted  into  the  acute  or  even  super- 
acute  variety. 

The  mild  or  subacute  variety  of  gonorrhea  is  not  fre- 


34       GONOREHEA  AND  ITS  COMPLICATIONS 

quent— as  a  first  attack.  It  is  seen  generally  in  people 
who  have  already  had  one  or  more  attacks  of  gonorrhea. 
And  it  is  sometimes  difficult  or  impossible  to  determine 
whether  we  have  to  deal  with  a  fresh  infection  or  with  an 
exacerbation  of  an  old  dormant  apparently  cured  gonor- 
rhea. 


v#-- 


ACUTE   GONORRHEAL  URETHRITIS 


\^i^ 

%% 


%u 


%&r 


NON-GONORRHEAL  URETHRITIS 


CHAPTER  VI 
TREATMENT  OF  ACUTE  GONORRHEA 

''Will  you  please  describe  briefly  your  method  of  treat- 
ing gonorrhea?"  I  do  not  know  how  many  times  I  re- 
ceived this  request  within  the  last  ten  years  from  physicians 
throughout  the  country,  who  knew  or  thought  that  I  had 
more  than  average  success  in  treating  this  disease.  It  is 
a  perfectly  legitimate  and  excusable  frailty  of  the  human 
mind  to  desire  short  cuts  to  knowledge  and  to  successful 
practice.  Alas,  there  are  no  short  cuts,  and  the  knowledge 
and  experience  acquired  in  twenty  years'  study  and  prac- 
tice cannot  be  transmitted  wholly  in  a  brief  article,  chapter 
or  even  book,  though  suggestions  can  be  offered  which  will 
help  the  student  on  the  right  road,  so  that  he  may  also  in  due 
time  become  an  expert. 

I  might  make  the  paradoxical  remark  that  the  reason 
my  method  of  treating  gonorrhea  is  perhaps  more  than 
usually  successful  is  because  I  have  no  method,  or  rather 
I  have  not  one  method,  I  have  a  hundred  methods.  No 
two  cases  of  gonorrhea  are  exactly  alike,  and  I  know  of 
no  disease  in  which  it  is  so  necessary  to  mix  brains  with 
your  medicines  as  it  is  in  the  treatment  of  gonorrheal 
urethritis. 

And  for  this  reason,  because  no  two  cases  of  gonorrhea 
are  exactly  alike,  it  is  so  difficult  to  outline  briefly  the 

35 


36       GONORRHEA  AND  ITS  COMPLICATIONS 

proper  method  of  treatment.  It  is  easy  enough  to  do  it 
provided  you  can  be  sure  that  the  physician  who  follows  it 
will  use  common  sense  and  judgment,  will  watch  the  reac- 
tion produced  by  the  treatment,  diminishing  or  increasing 
the  strength  for  instance  of  the  various  injections,  pro- 
longing or  shortening  the  intervals  of  their  administration, 
or  suspending  treatment  altogether.  Nevertheless  it  has  to 
be  done.  There  is  a  more  or  less  average  norm,  and  I  will 
therefore  proceed  to  describe  the  treatment  of  a  case  of 
average  severity,  reserving  special  remarks  for  the  excep- 
tionally acute  cases  on  the  one  hand  and  the  very  mild 
cases  on  the  other. 

The  treatment  of  gonorrhea  is  generally  divided  into 
general,  internal  and  local,  because  all  three  lines  of  treat- 
ment are  necessary  for  its  successful  treatment. 

GENERAL   MEASURES 

The  general  measures  may  be  expressed  in  the  words 
*' taking  things  easy."  If  the  patient  can  afford  it  he 
should  stay  home,  but  under  our  present  economic  and 
social  conditions  there  is  hardly  one  man  in  a  hundred 
who  can  stay  home  because  he  contracted  gonorrhea.  He 
would  risk  losing  his  job,  his  position,  or  he  would  ^'give 
away"  his  trouble  to  his  parents  or  his  wife,  which  is  just 
as  bad.  So  we  have  to  do  the  best  we  can.  We  therefore 
tell  him  he  should  stand  as  little  as  possible,  walk  as  little 
as  possible,  even  ride  as  little  as  possible,  and  to  recline  as 
much  as  possible.  He  should  be  particularly  careful  about 
lifting  things,  as  by  doing  so  he  may  invite  an  epididymitis. 
That  he  should  avoid  dancing,  horseback  riding,  bicycling, 


TREATMENT  OF  ACUTE  GONORRHEA    37 

goes  without  saying,  but  it  is  not  so  well  known  that  rail- 
road and  automobile  traveling  may  and  often  does  exert  a 
very  injurious  effect  on  an  acute  gonorrhea. 

Sexual  Rest.  Sexual  intercourse  is  to  be  strictly  pro- 
hibited, and  no  exceptions  are  to  be  made  to  this  rule.  One 
might  think  that  this  is  a  point  on  which  it  is  not  necessary 
to  spend  any  time,  but  those  who  think  so  do  not  know 
mankind  as  well  as  I  do.  I  personally  have  seen  many 
cases  in  my  practice  where  the  man  did  have  sexual  rela- 
tions during  the  acute  stage  of  an  acute  gonorrheal  urethri- 
tis. Some  did  it  just  because  they  were  vicious  brutes, 
some  did  it  because  they  were  married  men  and  were 
afraid  to  ''give  themselves  away"  to  their  wives.  These 
latter  used  condoms.  But  whether  with  or  without  any 
preventives,  intercourse  in  the  acute  stage  of  gonorrhea  is 
pernicious,  and  all  those  patients  had  their  cases  aggra- 
vated, developing  a  posterior  urethritis  or  a  prostatitis,  or 
both,  where  none  existed  before. 

Diet.  The  diet  should  be  moderate,  and  that  is  about  all. 
I  do  not  see  the  necessity  of  limiting  the  patient  to  a  strict 
diet  as  some  of  our  other  urologists  do.  The}^  may  follow 
their  usual  diet,  merely  taking  care  to  leave  out  all  spices, 
condiments  and  salty  or  acid  articles  of  food.  Meat  is  not 
injurious,  though  it  is  better  to  eat  of  it  sparingly. 

Beverages.  All  alcoholics  of  whatever  nature  are 
strictly  prohibited.  I  do  not  take  any  of  the  statements  of 
our  older  writers  for  granted,  but  that  alcoholics  are  in- 
jurious in  an  acute  gonorrhea  I  have  convinced  myself 
many  times.  Coffee  is  also  best  cut  out  because  it  has  an 
irritating  effect  on  the  sexual  organs,  but  weak  tea  may  be 


38       GONORRHEA  AND  ITS  COMPLICATIONS 

dmnk  freely.  The  best  thing  to  drink  during  an  acute 
gonorrhea  is  milk,  buttermilk,  and  plenty  of  plain  water. 
Those  who  do  not  like  plain  water  may  drink  a  mild  al- 
kaline mineral  water.  Carbonated  beverages,  however, 
should  be  avoided,  except  in  small  quantities. 

Smoking  is  perfectly  permissible. 

Among  the  other  general  measures  it  is  only  necessary 
to  mention  two:  the  patient's  bowels  and  bath.  The  pa- 
tient must  see  to  it,  or  the  doctor  must  see  for  him,  that  he 
does  not  get  constipated.  A  constipated  bowel  has  a  bad 
effect  on  an  acute  gonorrhea.  It  has  a  bad  effect  for  two 
reasons,  both  because  it  increases  the  general  toxemia  of 
the  system,  and  because  mechanically,  by  the  feces  press- 
ing on  the  prostate  and  the  patient  straining  during  defeca- 
tion, the  inflammation  is  aggravated. 

Hot  baths  are  very  useful,  and  they  should  be  taken  as 
sitz  baths  or  hip  baths.  I  am  afraid  of  a  gonorrheal  patient 
taking  a  full  bath.  I  always  fear  that  some  of  the  pus, 
minute  as  the  amount  may  be,  may  be  washed  off  the 
urethra  and  reach  his  eyes. 

That  the  patient  should  wash  his  hands  each  time  after 
touching  his  penis  and  that  the  danger  of  transmitting  the 
pus  from  the  urethra  to  the  eyes  should  be  thoroughly  em- 
phasized to  him,  also  goes  without  saying. 

It  sometimes  happens,  however,  that  the  physician,  either 
because  he  is  very  busy,  with  an  office  full  of  patients  wait- 
ing, or  for  other  reasons,  forgets  to  give  the  patient  some 
very  necessary,  some  vital  instructions.  It  is  therefore  a 
good  idea  to  have  a  printed  leaflet  which  contains  the  nec- 
essary instructions,  and  to  give  it  to  each  patient.  It  not 
only  avoids  the  danger  of  forgetting,  but  it  saves  time. 


TREATMENT  OF  ACUTE  GONORRHEA    39 

For  many  years  I  have  been  in  the  habit  of  giving  each 
patient  with  acute  gonorrhea  the  following  leaflet : 

PERSONAL  INSTRUCTIONS 

AND   SUGGESTIONS 

William  J.  Robinson,  M.D. 
12  Mount  Morris  Park  West 

NEW   YOEK 

1.  Uncomplicated  gonorrhea  is  a  comparatively  mild  disease,  and 
can  be  quickly  (3  to  6  weeks)   and  permanently  cured. 

2.  The  disease  is,  however,  very  apt  to  cause  complications,  and 
then  it  becomes  one  of  the  most  difficult  and  tedious  diseases  to 
treat.  The  prostate,  bladder,  kidneys,  joints,  heart,  may  become 
infected.  In  fact,  there  is  hardly  an  organ  in  the  body  which  may 
not  become  infected  with  the  germ  of  .  gonorrhea  ( gonococcus )  or 
its  poison   ( gonotoxin ) . 

3.  Do  not  believe  in  any  stories  of  3  and  5  day  cures.  If  a 
gonorrhea  was  ever  cured  in  three  or  five  days,  it  wasn't  a  gonorrhea. 
It  was  probably  a  catarrh  of  the  urethra. 

4.  The  gonorrheal  discharge  or  pus  is  fearfully  contagious,  and 
you  must  observe  the  most  scrupulous  cleanliness.  Bringing  the 
discharge  in  contact  with  your  eyes  may  cost  you  your  eyesight. 
After  the  slightest  contact  wash  your  fingers  in  the  antiseptic  so- 
lution I  gave  you. 

5.  Always  urinate  before  injecting.  If  you  are  unable  to  urinate 
at  a  certain  given  time,  then  don't  inject.     Wait. 

6.  After  urinating,  and  before  injecting,  wash  the  glans  and  the 
meatus  with  a  piece  of  gauze  or  cotton  dipped  in  the  antiseptic 
solution. 

7.  Keep  the  syringe  scrupulously  clean.  The  tip  should  be  kept 
in  the  antiseptic  solution  all  the  time. 

8.  If  you  follow  the  instructions  that  I  gave  you,  you  cannot 
inject  too  often.  If  you  can  inject  every  hour,  do  so.  If  you  can- 
not inject  so  often,  then  inject  as  often  as  you  can. 

9.  If  I  ordered  for  you  two  or  three  different  injections,  then  it 
is  preferable  to  get  two  or  three  syringes,  keeping  one  for  each 
injection. 

10.  If  your  case  is  an  acute  one,  then  you  must  cut  off  alcoholic 


40       GONORRHEA  AND  ITS  COMPLICATIONS 

liquors  of  whatever  character  absolutely.  Tea  and  coffee  and  car- 
bonated waters  are  also  best  left  off.  Very  weak  cold  tea  is  not 
injurious. 

11.  I  have  no  objection  to  your  smoking.  Smoke  as  much  as  you 
want  to. 

12.  Drink  plenty  of  milk,  water,  flax-seed  tea,  etc.  The  oftener 
you  urinate  the  better,  for  the  urethral  canal  is  flushed  and  the  pus 
is  not  allowed  to  accumulate.  But  do  not  drink  much  after  7  p.  m., 
as  the  distension  of  the  bladder  during  the  night  with  urine  is  apt 
to  cause  irritation  and  chordee. 

13.  Do  not  allow  yourself  to  go  constipated.  If  you  are,  say  so, 
and  a  mild  laxative  will  be  given  you. 

14.  Eat  little  and  only  mild,  unseasoned  foods.  Avoid  staying 
up  late,  and  eat  nothing  for  three  or  four  hours  before  going  to  bed. 

15.  The  last  injection  should  be  made  after  the  last  urination, 
immediately  before  going  to  bed.  Do  not  sleep  on  your  backj  sleep 
on  your  side,  preferably  the  right  side. 

16.  Walk  and  stand  as  little  as  you  possibly  can.  The  semi- 
reclining  position  is  the  best.  Bicycling,  horseback  riding,  dancing, 
etc.,  are  of  course  very  injurious. 

17.  It  should  not  be  necessary  to  state  that  intercourse  during 
an  acute  gonorrhea  is  criminal  folly.  Still  I  have  found  by  experi- 
ence that  this  admonition  is  not  superfluous. 

18.  The  cessation  of  the  discharge  does  not  necessarily  signify 
that  the  disease  has  been  radically  cured.  There  may  be  no  dis- 
charge whatsoever  and  still  nimierous  gonococci  may  be  lurking  in 
the  submucous  tissue,  in  the  little  glands  and  follicles,  in  the  pros- 
tate, etc.,  and  may  be  awakened  to  renewed  activity  at  the  first 
intercourse  or  the  first  glass  of  beer.  You  are  not  cured  until  you 
have  been  pronounced  cured  by  a  competent  authority;  and  this 
can  only  be  done  after  two  or  three  thorough  examinations,  with  the 
aid  of  the  microscope,  complement  test,  etc. 

19.  Do  not  get  married  until  permission  has  been  given  you  by  a 
competent  authority,  after  a  thorough,  painstaking  examination, 

20.  If  your  physician  is  not  enjoying  your  fullest  and  most  abso- 
lute confidence,  change  him,  and  the  sooner  you  do  it  the  better. 
It  is  unfair  to  yourself  and  to  him  to  pursue  treatment  in  a  half- 
hearted manner. 


TREATMENT  OF  ACUTE  GONORRHEA    41 

INTERNAL   TREATMENT 

It  is  said  that  there  are  some  urologists  who  pride  them- 
selves on  treating  acnte  gonorrhea  without  any  internal 
medicine,  particularly  without  the  balsamics.  May  the 
good  Lord  forgive  them.  How  any  one  who  has  ever  no- 
ticed the  remarkable,  repeated  and  certain  effect  of  a  good 
oil  of  sandalwood  in  diminishing  the  dysuria,  the  pain  and 
burning,  and  the  discharge  in  an  acute  gonorrhea,  can 
deliberately  deprive  himself  of  the  adjuvant  effect  of  this 
and  similar  agents,  is  beyond  my  comprehension. 

The  average  human  mind  is  narrow  and  loves  to  follow 
methods  and  systems :  one  must  necessarily  be  an  internist, 
the  other  a  localist.  Why  not  call  into  action  the  aid  of  all 
possible  remedies  and  methods  of  treatment?  So  con- 
vinced am  I  of  the  value  of  internal  treatment  in  acute 
gonorrhea  that  if  I  were  limited  in  the  treatment  of  this 
disease  to  either  internal  or  local  treatment  I  would  choose 
the  former.  (It  is  just  the  opposite  in  subacute  and 
chronic  gonorrhea:  there  the  local  treatment  is  much  more 
important  than  the  internal;  but  this  will  be  discussed  in 
a  future  chapter.) 

The  first  internal  prescription  I  give  has  generally  the 
following  composition: 

^     Potassii  citratis,  5  ij 
Potassii  bromidi,  3  ij 
Liquor  potassii  hydroxidi,  3  i 
Ext.  hyoscyami  fl.  3  i 
Ext.  tritici  fl.  3  vi 
Aquae,  q.s.  ad,  5  vi 


42       GONOKRHEA  AND  ITS  COMPLICATIONS 

Sig.  Tablespoonful  three  or  four  times  a  day  in,  or  fol- 
lowed by,  half  a  glass  of  water. 

Where  the  urine  is  excessively  acid  and  there  is  strong 
ardor  urinae  this  combination  acts  surely  and  well.  It 
quickly  neutralizes  the  acidity  of  the  urine,  the  act  of  urina- 
tion is  made  much  less  unpleasant,  and  the  patient's  sub- 
jective symptoms  are  decidedly  improved.  It  also  acts  to 
a  certain  extent  as  a  preventive  of  chordee.  This  prescrip- 
tion lasts  three  or  four  days,  depending  upon  whether  the 
patient  takes  it  four  or  three  times  a  day,  and  is  as  a  rule 
not  repeated. 

Where  the  urine  is  not  very  acid  I  leave  out  the  liquor 
potassii  hydrox.  and  often  I  leave  out  the  fluid  extract  of 
hyoscyamus  and  give  instead  tablets  or  granules  of  hyos- 
cyamine  1-100  gr.  three  or  four  times  a  day,  or  atropine 
sulphate  1-150  gr.  twice  or  three  times  a  day. 

I  believe  that  this  prescription,  given  at  the  beginning 
of  the  acute  stage  of  the  disease,  has  a  definitely  beneficial 
effect  in  limiting  the  inflammation.  When  the  patient  is 
through  with  this  prescription  I  begin  the  administration 
of  what  we  call  the  balsamics.  The  balsamics  most  com- 
monly in  use  are  oil  of  sandalwood,  copaiba  and  cubebs, 
which  latter  may  be  administered  in  the  form  of  the  pow- 
dered cubebs  or  the  fluid  extract  of  cubebs  or  the  oil  of 
cubebs  or,  which  is  the  best  preparation,  oleoresin  of  cubebs. 
Personally,  however,  I  have  completely  discarded  copaiba 
and  cubebs  in  my  private  practice  (we  still  have  to  pre- 
scribe copaiba  to  dispensary  patients)  and  have  limited 
myself  exclusively  to  oil  of  sandalwood  and  its  combina- 
tions or  derivatives. 


TREATMENT  OP  ACUTE  GONORRHEA    43 

I  prescribe  them  only  in  capsule  form;  it  seems  to  me 
an  unnecessary  cruelty  to  the  patient  to  give  him  sandal- 
wood either  on  sugar  or  in  water  or  in  the  emulsion  form. 
I  generally  prescribe  two  5  minim  capsules  three  to  four 
times  a  day,  the  patient  thus  taking  thirty  or  forty  minims  a 
day.  I  either  give  no  sandalwood  at  all  or  if  I  give  it,  I 
give  it  in  what  I  consider  efficient  doses.  To  youthful  or 
very  delicate  persons  five  minims  four  times  a  day  is  often 
sufficient. 

Many  patients  have  no  trouble  whatever  in  taking  oil 
of  sandalwood,  and  these  patients  need  no  other  internal 
treatment.  Many  patients,  however,  cannot  take  it  for  two 
reasons:  either  it  upsets  their  stomach,  causing  belching, 
anorexia,  or  it  causes  pain  across  the  kidneys.  Some- 
times the  pain  may  be  quite  acute.  To  such  patients  we 
must  give  some  of  the  various  combinations  and  derivatives 
of  oil  of  sandalwood.  I  frequently  prescribe  gonosan, 
santyl,  lactosantal,  thyresol,  and  arrheol.  The  dose  of  all 
of  them  varies  from  one  to  two  capsules  three  to  four  times 
a  day.  Thyresol  may  also  be  given  in  tablet  form. 
Arrheol  may  be  given  in  doses  of  from  eight  to  twelve  cap- 
sules a  day.  Where  pain  in  the  urethral  canal  and  at  the 
neck  of  the  bladder  is  a  prominent  symptom  gonosan  acts 
best,  because  it  possesses,  besides  its  antiblenorrhagic  ef- 
fects due  to  the  santal  oil,  distinctly  anodyne  effects  due 
to  the  kava-kava.  , 

That  is  all  the  medicine  the  patient  takes  for  his  gonor- 
rhea as  such.  This  is  continued  throughout  the  course  of 
the  disease,  with  the  difference  that  after  the  third  week, 
when  the  discharge  has  greatly  diminished,  only  two  or 
three  five  minim  capsules  are  taken  pro  die. 


44      GONOREHEA  AND  ITS  COIVIPLICATIONS 

Special  symptoms,  such  as  chordee,  balanitis,  etc.,  re- 
quire special  treatment,  which  is  considered  under  the  ap- 
propriate heading. 

I  do  not  give  hexamethylenamine  as  a  routine  drug  in 
gonorrhea.  I  could  not  convince  myself  that  it  had  any 
beneficial  effect.  Sometimes  it  aggravates  the  condition  by 
making  the  urination  more  painful.  Where  there  is  a 
mixed  infection,  however,  there  it  is  given  invariably,  but 
then  we  must  see  to  it  that  the  urine  is  not  alkaline,  for 
hexamethylenamine  (urotropin)  acts  but  feebly  or  not  at 
all  in  an  alkaline  medium.  In  such  cases  1  usually  pre- 
scribe it  in  conjunction  with  sodium  benzoate,  which  acidi- 
fies the  urine  or  with  the  recently  introduced  sodium  acid 
phosphate,  NaH2P04,  whose  action  is  still  more  certain  in 
this  respect.  This  salt  is  not  the  official  sodium  phosphate, 
which  is  chemically  the  disodic  hydrogen  phosphate, 
Na2HP04,  and  which  is  used  as  a  cholagogue  and  laxative. 
The  salt  I  am  referring  to  is  given  in  doses  of  ten  to  30 
grains  three  times  a  day.  It  may  be  given  in  the  form  of 
tablets  containing  both  hexamethylenamine  and  the  mono- 
sodic  acid  phosphate — ^five  grains  of  the  former  and  ten  to 
fifteen  grains  of  the  latter. 

Hexamethylenaminae,  gr.  v 
Sodii  benzoatis,  gr.  x 
Mf.  pulv.  No.  i 
Tales  doses.  No.  xij 
S.     One  powder  in  a  glass  of  water  three  to  four  times 
a  day. 

Hexamethylenaminae,  gr.  vij  ss 
Sodii  (mono)  acidi  phosphatis,  gr.  xv 


TREATMENT  OF  ACUTE  GONORRHEA   45 

M.f.  tabella,  No.  i 
Tales  doses  No.  xxx 
S.     One  in  a  glass  of  water  three  to  four  times  a  day. 

Methylene  blue  is  a  peculiar  drug,  and  though  it  has 
been  used  for  many  years  in  the  treatment  of  gonorrhea  it 
is  still  impossible  to  define  its  status.  In  some  cases  it 
seems  to  act  nicely,  in  a  large  number  not  at  all.  Occa- 
sionally when  the  patient  becomes  intolerant  of  santal  oil 
preparations  it  is  necessary  to  make  a  change,  and  then  I 
prescribe  it.  It  should  never  be  prescribed  alone,  but  al- 
ways with  some  extract  of  belladonna  and  a  small  amount 
of  cinnamon ;  nutmeg  is  not  advisable  in  the  acute  stages : 

Methylthioninae  hydrochlor.,  gr.  ij 
Phenyl  salicylatis,  gr.  iij 
Extr.  belladonnae,  gr.  1-6 
Pulv.  cinnamomi,  gr.  ss 
M.f.  capsula  No.  i 
Tales  doses  No.  xxx 
S.     One  capsule  three  to  four  times  a  day. 

LOCAL   TREATMENT 

The  injection  treatment  of  gonorrhea  is  still  a  mooted 
question.  It  is  a  genuine  bete  noire.  Many  physicians 
even  nowadays  are  afraid  of  it.  There  is  no  effect  without 
a  cause,  and  there  is  a  cause  for  the  suspicious  and  timid 
attitude  of  the  profession  towards  the  injection  treatment. 
The  fear,  which  is  in  many  instances  a  wholesome  fear,  is 
due  to  the  fact  that  injections,  if  given  in  the  superacute 
stage  of  gonorrhea,  or  if  administered  bunglingly  and 
forcibly,  or  if  too  strong  in  themselves  or  in  too  strong 


46       GONORRHEA  AND  ITS  COMPLICATIONS 

a  concentration,  are  apt  to  do  a  great  deal  of  damage.  Very 
many  strictures  were  undoubtedly  caused  by  the  too  pow- 
erful injections  used  by  our  forefathers.  Even  at  this 
late  day  we  not  rarely  see  cases  in  which  an  injection 
administered  by  the  patient  himself,  or  even  occasionally 
by  the  physician,  has  caused  an  almost  immediate  exten- 
sion of  the  inflammation  to  the  posterior  urethra,  or  severe 
strangury  with  retention  of  urine,  or  hemorrhage,  or 
epididymitis,  or  prostatitis.  And  when  one  deals  with 
patients  of  a  low  degree  of  intelligence  who  cannot  be 
taught  not  only  how  to  be  aseptic  but  even  how  to  be 
ordinarily  clean,  it  is  best  to  leave  out  injections  altogether; 
and  the  physician  who  has  not  or  does  not  want  to  take  the 
requisite  time  and  the  required  gentleness  for  the  trifling 
but  important  process  of  washing  out  and  injecting  the 
urethra  should  also  leave  injections  alone.  It  will  not  be 
the  best  kind  of  treatment,  but  no  injections  are  better 
than  carelessly  or  imperfectly  administered  injections.  So, 
as  saidj  there  is  a  real  reason  for  the  fear  of  injections. 

But,  as  we  have  said  many  times  before,  the  improper 
use  or  abuse  of  a  measure  does  not  militate  against  its 
proper  use.  And  the  conscientious  and  careful  practitioner 
need  have  no  hesitation  in  resorting  to  the  treatment  of 
gonorrhea  by  injections.  I  begin  to  use  them  with  the 
patient's  very  first  visit.  The  only  class  of  cases  I  do  not 
use  them  in  is  in  the  superacute  cases,  but  this  is  really 
not  necessary  to  mention,  because  it  will  be  mentioned  later 
on,  and  it  is  the  cases  of  moderate  severity  that  I  am  dis- 
cussing here — this  should  all  the  time  be  borne  in  mind. 

The  drugs  used  for  injection  are  certainly  very  numer- 
ous, as  is  readilj^  seen  by  referring  to  the  section  on  drugs. 


TREATMENT  OF  ACUTE  GONORRHEA    47 

While  it  is  good  to  have  a  large  number  to  select  from,  for 
very  frequently  a  ease  which  will  not  yield  to  one  drug 
will  yield  to  another,  still  in  the  majority  of  eases  we  limit 
ourselves  to  a  small  number  of  drugs,  and  it  is  to  these 
only  that  we  will  refer  in  this  chapter. 

The  injections  may  be  divided  into  three  classes :  cleans- 
ing, antigonoeoccal  and  astringent. 

While  these  injections  may  be  used  interchangeably  dur- 
ing one  and  the  same  period,  still,  as  a  rule,  each  class  is 
indicated  for  a  different  stage  of  the  disease.  When  a 
patient  comes  in  a  superacute  condition,  with  the  discharge, 
so  to  say,  bursting  forth,  and  the  penis  red,  swollen  and 
painful,  then  I  use  only  the  cleansing  injections.  But  this 
stage  under  proper  management  never  lasts  longer  than 
two  or  three  days,  and  then  the  time  comes  for  the  anti- 
gonoeoccal or  genocide  or  antiseptic  injections.  Many 
patients  never  have  that  very  acute  stage;  that  is,  even  a 
first  or  acute  gonorrhea  may  start  in  and  proceed  with  only 
moderate  symptoms.  In  such  cases  the  cleansing  injec- 
tions are  left  out  and  the  gonocide  injections  are  com- 
menced forthwith.  The  astringent  injections  are  reserved 
for  the  last  or  declining  stage,  when  there  is  but  a  drop  or 
so  of  discharge  and  gonococci  are  either  entirely  absent 
or  very  scant. 

The  most  eligible  cleansing  solutions  are  a  one  per  cent, 
solution  of  borax  or  sodium  bicarbonate  or  l-lOth  per  cent, 
solution  of  sodium  chloride.  Boric  acid  is  not  very  good 
for  the  purpose,  for  mild  as  it  is,  it  is  still  nevertheless 
irritating,  occasionally. 

It  is  best  to  prescribe  those  solutions  double  the  strength 
that  it  is  intended  the  patient  should  use  and  direct  him 


48      GONORRHEA  AND  ITS  COMPLICATIONS 

to  dilute  them  half  and  half  with  boiling  water.  For  it  is 
important  the  patient  should  use  the  solution  hot.  If  he 
can  use  it  of  a  temperature  of  45°  C.  (113°  F.)  he  will 
kill  two  birds  at  one  shot,  because  the  above  temperature 
is  fatal  to  the  gonococcus.  But  in  the  superacute  stage  of 
which  we  are  speaking  now,  some  patients  are  very  sensi- 
tive to  heat  and  cannot  stand  a  higher  temperature  than  90 
or  100°  F.  A  higher  temperature  is  not  only  painful  but 
occasionally  increases  the  inflammation. 

We  must  always  remember  the  purpose  of  these  injec- 
tions: they  are  merely  cleansing  and,  unlike  injections  of 
class  two  and  three,  they  are  not  to  be  held  in  the  urethra. 
They  are  injected  and  allowed  to  run  right  out.  Of  course, 
as  with  all  injections,  the  patient  must  be  instructed  always 
to  urinate  before  using  the  injection.  If  he  cannot  urinate 
at  a  given  time,  then  he  is  to  delay  the  injection  until  he 
can. 

I.      FORMULAS   OF   CLEANSING  INJECTIONS: 

1.  Sodii  bicarbonatis,  gr.  cl 
Aquae  destill.  steriliz.,  Oj 

Mix  with  equal  volume  of  hot  water  and  inject  two  or 
three  syringefuls  every  hour  or  two.  (If  you  cannot  do  it 
so  often,  do  it  as  often  a«  you  can.) 

2.  Sodii  boratis,  gr.  cl. 
Aquae  destill.*  steriliz.,  Oj 

Directions  same  as  with  injection  No.  1. 

3.  Sodii  chloridi  c.  p.,  gr.  xxx 
Aquae  destill.  steriliz.,  Oij 

Directions  same  as  with  No.  1. 


TREATMENT  OF  ACUTE  GONORRHEA   49 

Some  use  a  normal  salt  solution  (0.7  to  0.9  per  cent.)- 
I  don't  consider  it  necessary  to  use  the  solution  so  strong. 

We  now  come  to  the  formulas  for  the  gonocide  solutions. 
There  is  but  little  limit  to  the  frequency  of  the  injections. 
If  one  would  use  the  injections  regnilarly  every  hour  or 
two,  his  urethritis  would  certainly  be  cured  in  a  very  short 
time.  These  injections  are  to  be  held  in  as  long  as  pos- 
sible— fifteen  minutes  (if  the  patient  has  the  patience  and 
perseverance),  ten  minutes,  or  at  least  five  minutes.  If  the 
patient  (after  urinating,  of  course)  takes  the  injection  in 
the  recumbent  or  semi-recumbent  position,  he  will  have 
less  difficulty  in  retaining  the  solution  as  long  as  may  be 
necessary. 

The  antiseptics  that  have  been  recommended  as  gonocides 
are  many.  The  principal  ones  are  mercuric  chloride  (cor- 
rosive sublimate),  potassium  permanganate,  hydrogen 
peroxide,  thalline  sulphate,  ichthyol  and  silver  salts.  Mer- 
curic cliloride  is  mentioned  here  only  to  be  condemned  in 
the  most  emphatic  terms.  It  is  a  drug  that  works  mis- 
chief with  the  urethral  canal.  The  urethral  mucosa  is  an 
exceedingly  delicate  membrane  and  must  be  dealt  with 
gently.  We  must  kill  the  gonococci,  but  we  must  not  de- 
stroy the  mucous  membrane.  I  am  satisfied  that  many 
cases  of  stricture,  urethral  erosion  and  other  complications 
can  be  laid  at  the  door  of  corrosive  sublimate.  Potassium 
permanganate  is  not  one  of  my  prime  favorites.  If  used 
in  strength  to  be  efficient  it  is  too  irritating.  Not  that  we 
cannot  cure  a  gonorrhea  with  it  alone,  but  there  are  better 
drugs,  and  in  medicine  the  best  is  none  too  good.  Still  in 
some  cases  it  seems  to  be  superior  to  any  drug  in  or  out  of 
the  pharmacopeia. 


50      GONORRHEA  AND  ITS  COMPLICATIONS 

Hydrogen  peroxide  is  of  little  value  as  a  gonocide. 
When  I  do  use  it,  it  is  in  very  dilute  solution  as  a  cleansing 
agent,  merely  preliminary  to  the  gonocide  injection.  Thai- 
line  sulphate  is  a  well  tried  gonocide  and  I  use  it  fre- 
quently. Ichthyol  I  use  in  obstinate  cases  of  a  gleety  char- 
acter. But  the  gonocide  drugs  par  excellence  are  the  silver 
compounds. 

The  best  kaown  of  silver  compounds  is  silver  nitrate.  I 
use  it  very  extensively  in  chronic  urethritis,  but  to  use  it 
in  acute  gonorrhea  would  be  folly.  It  not  only  increases 
the  pain  and  the  discomfort  (often  producing  retention, 
strangury,  blood  in  the  urine,  etc.)  but  actually  aggravates 
the  disease.  For  the  silver  nitrate  increases  the  discharge, 
and  the  more  abundant  the  discharge  the  better  the  gono- 
cocci  like  it;  this  is  their  pabulum  and  they  multiply  in  it 
much  more  rapidly  than  in  a  urethra  with  but  a  scanty 
discharge.  For  this  reason  my  endeavor  from  the  first 
minute  I  get  the  patient  is  to  reduce  the  amount  of  dis- 
charge in  the  urethra  to  a  minimum;  not  by  the  aid  of 
drying  astringents,  but  by  mechanical  means ;  by  frequently 
flushing  the  urethra  with  the  syringe  and  by  making  the 
patient  take  lots  of  liquid,  so  that  he  is  obliged  to  urinate 
very  often  and  thus  wash  his  urethra  from  within.  And 
so  nitrate  of  silver  in  acute  gonorrheal  urethritis  is  out  of 
the  question.  Silver  iodide,  recently  recommended,  is  of 
little  or  no  value.     Silver  fluoride  is  irritating. 

In  short,  the  inorganic  preparations  of  silver  are  not  well 
suited  for  the  treatment  of  acute  gonorrhea.  We  must 
have  recourse  to  the  organic  compounds.  Here  we  are 
confronted  with  an  embarras  des  richesses.  We  have  pro- 
targol,  argyrol,  argonin,  argentamine,  argentose,  argentol, 


TKEATMENT  OF  ACUTE  GONORRHEA    51 

nargol,  largin,  picratol,  silberol,  ichtrargan,  albargin,  etc., 
etc.  While  I  have  given  every  one  of  them  a  pretty  thor- 
ough trial,  I  shall  not  go  into  a  consideration  of  the  ad- 
vantages and  disadvantages  of  every  one  of  them.  I  will 
simply  state  that  practically  I  have  limited  myself  to  the 
first  mentioned,  namely  protargol  and  argyrol.  And  while 
argentamine,  argonin  and  albargin  are  used  abroad  con- 
siderably, in  this  country  the  above  two  compounds  are 
the  only  ones  in  general  use. 

Arg^^rol  is  an  excellent  silver  compound  and  is  the  least 
irritating  of  all  silver  compounds.  And  in  very  irritable 
or  sensitive  urethras  that  is  the  silver  compound  of  choice. 
Protargol,  however,  seems  to  be  more  penetrating  and  on 
the  whole  is  more  effective.  An  excellent  way  is  to  use,  as 
I  have  been  doing  for  some  time,  the  two  salts  alternately. 
That  is,  I  will  prescribe  one  bottle  of  protargol  solution 
and  one  of  argyrol  and  tell  the  patient  to  use  the  protargol 
one  day  and  argyrol  the  next  day,  or  to  change  with  each 
injection.  Under  these  injections  the  secretion  diminishes, 
the  inflammation  subsides  and  the  gonococci  disappear 
rapidly. 

n.      FORMULAS   FOR  GONOCIDE   SOLUTIONS 

4.     Protargol,  0.5 

Aquae  destill.,  200.0 

M.  Ft.  solutio  lege  artis.     Detur  in  vitro  nigro. 

Sig.    Use  one  syringeful  at  a  time  (two  to  four  drams, 

depending  on  the  capacity  of  the  man's  anterior  urethra, 

which  I  always  measure)  and  hold  in  five  to  ten  minutes. 

You  must  be  sure  that  the  solution  of  protargol  is  prop- 


52      GONORRHEA  AND  ITS  COIMPLICATIONS 

erly  prepared.  Improperly  prepared  it  contains  lumps 
and  will  prove  irritating.  The  best  way  to  make  a  solu- 
tion of  protargol  is  to  pour  the  water  into  a  wide  graduate 
or  a  mortar,  and  then  throw,  with  a  sifting  motion,  the 
protargol  on  the  water;  it  is  light  and  floats.  Leave  it 
without  shaking  or  stirring;  in  a  few  minutes  it  will  be 
found  to  have  become  dissolved.  As  seen,  I  commence 
with  a  1/4  per  cent,  solution  (1:400).  The  amount  may  be 
raised  to  one  or  two  per  cent,  but  I  seldom  go  beyond  one 
per  cent. 

5.  Argyrol,  10.0—20.0—50.0 
Aquae  destilL,  200.0 

Use  the  same  way  as  the  protargol  solution. 

6.  Thalline  sulph.,  1.0 
Aquae  destilL,  200.0 

This  is  a  one-half  per  cent,  solution ;  the  strength  may  be 
raised  to  two  per  cent.,  but  one  per  cent,  is  generally  the 
most  satisfactory. 

7.  Ichthyol,  4.0  to  6.0 
Aquae  destilL,  200.0 

This,  as  stated  previously,  is  used  only  in  ''dragging" 
cases  and  is  good  as  an  alternate  injection. 

When  the  discharge  has  become  thin,  serous  and  scanty, 
when  the  gonococci  are  practically  absent,  then  it  is,  as  a 
rule,  advisable  to  finish  up  with  an  astringent  injection. 
For  this  purpose  we  may  use  one  of  the  following  injec- 
tions. 


TREATMENT  OF  ACUTE  GONORRHEA    53 


ni.      FORMULAS  FOR   ASTRINGENT   INJECTIONS 

8.  Zinci  sulpliatis,  gr.  viij 
Aquae  destilL,  5  iv 

Inject  three  or  four  times  a  day. 

9.  Zinci  sulpliatis,  gr.  viij 
Plumbi  acetatis,  gr.  viij 
Aquae  destilL,  5  iv 

Shake  well.     Inject  three  or  four  times  a  day. 

10.  Zinci  sulphocarbolatis,  gr.  xvj 
Aquae  destilL,  §  iv 

11.  Zinci  sulphatis 

Plumbi  acetatis,  aa  gr.  viij 
Tr.  opii,  o  j 
Tr.  catechu,  5  ij 
Aquae  ad,  §  iv 

The  foUowing,  however,  is  my  favorite: 

12.  Zinci  sulphatis,  gr.  viij 

Bismuthi  subcarbon  (vel  subnitr.),  3  iij 
Bismuthi  subgalL,  5  j 
Hydrastis  aquos,  §  j 
Pulv.  acaciae,  3  jss 
Aquae  ad  §  iv 
M.  f.  mistura  lege  artis. 
Keep  bottle  flat  and  shake  well  before  using. 

This  leaves  a  protecting  coating  over  the  urethral  canal, 
exerting  a  soothing  and  healing  influence.     The  coating 


54       GONORRHEA  AND  ITS  CO]\IP  LI  CATIONS 

remains  in  the  urethra  until  the  next  urination.     This  in- 
jection finishes  up  the  treatment. 

[If  prepared  by  a  competent  pharmacist  this  prescrip- 
tion makes  a  smooth  homogeneous  mixture,  like  an  emul- 
sion. Prepared  by  an  incompetent  pharmacist,  it  is  lumpy, 
gritty,  and  often  proves  irritating  to  the  urethra.] 


CHAPTER  VII 
CASE  REPORTS 

Before  going  further,  I  will  present  two  typical  cases  of 
acute  gonorrhea — first  attacks — the  method  of  actual  treat- 
ment pursued,  and  the  difference  in  the  results  obtained, 
on  account  of  a  slight  misstep  on  the  part  of  one  patient. 

A.  A.,  age  26,  made  a  night  of  it  on  December  1st.  He 
had  a  big  dinner,  drank  a  good  deal  of  wine,  and  had  in- 
tercourse four  or  five  times.  In  short  he  did  comply  with 
all  the  requirements  which  Ricord  gave  as  necessary  in 
order  to  be  certain  to  get  a  gonorrhea.  The  woman  ap- 
parently supplied  the  gonococcus.  On  December  4th  he 
felt  a  tickling  in  the  meatus,  towards  evening  of  the  same 
day  he  felt  considerable  burning  in  the  urethral  canal,  and 
the  meatus  became  puffy.  On  the  morning  of  the  5th  he 
woke  up  early  with  a  painful  erection  and  some  discharge. 
Urination  was  scalding  and  painful.  During  the  day  the 
discharge  gradually  increased  and  urination  became  more 
and  more  painful.  He  was  sure  that  the  woman,  a  re- 
spectable young  widow,  was  clean  and  healthy,  and  there- 
fore he  could  not  have  anything  serious.  He  thought  it 
was  all  due  to  a  strain.  He  bathed  his  penis  in  hot  water, 
which  relieved  him  temporarily.  The  following  day  things 
kept  on  going  from  bad  to  worse,  and  on  December  7th  he 
came  to  consult  me.  He  had  never  had  any  venereal 
trouble,  in  fact  prior  to  that  night  he  had  had  no  inter- 

55 


56      GONORRHEA  AND  ITS  COMPLICATIONS 

course  for  six  months — ^having  been  away  to  Mexico  and 
having  a  wholesome  fear  of  the  tropical  women;  and  this 
was  his  first  attack. 

Status  prcesens.  The  meatus  puffy,  the  glans  swollen, 
the  entire  penis  very  hot,  the  prepuce  swollen  and  edemat- 
ous, though  retractable,  and  a  large  amount  of  greenish 
pus  pouring  out  of  the  meatus.  A  little  tenderness  in  the 
right  groin,  showing  beginning  involvement  of  the  inguinal 
glands.  I  tell  him  to  urinate,  and  the  urine  comes  out 
slowly  and  in  a  very  thin  stream,  showing  great  congestion 
of  the  urethral  canal.  Urination  exceedingly  painful,  and 
he  grits  his  teeth  during  the  process.  The  last  few  drops 
of  urine  look  as  if  they  were  tinged  with  blood.  He  passed 
altogether  about  six  ounces  of  urine,  in  three  separate 
glasses,  and  each  portion  is  a  little  turbid,  though  the  last 
only  slightly  so.  The  urine  is  very  dark  in  color  and  very 
acid.  Though  no  microscopic  examination  was  necessary 
— the  diagnosis  was  perfectly  plain  without  it — still  one 
was  made,  and  it  showed  the  presence  of  numerous  extra- 
and  intracellular  gonococci. 

To  think  of  attempting  to  abort  a  case  like  this  would 
have  been  absurd.  Nor  did  I  think  it  advisable  to  use  any 
injections  at  that  stage.  Antiseptic  or  ''gonocide"  injec- 
tions would  have  proved  irritating,  and  all  that  could  be 
accomplished  by  cleansing  injections  could  as  well  be  ac- 
complished by  washings  from  within — by  the  frequent  pass- 
ing of  a  bland,  diluted  urine. 

I  gave  him  the  following  mixture: 

^     Potassii  citratis,  5  ij 
Sodii  bromidi,  3  iij 


CASE  REPORTS  57 

Liq.  potassae,  3  i 
Ext.  hyoscyami.  fl.,  5  i 
Aquae  menthae  pip.  q.s.ad  §  vj 
Sig.    §  ss  in  water  four  times  a  day. 

Besides  this  I  gave  him  arbutin  pills,  one  gr.  each,  one  to 
be  swallowed  every  hour,  followed  by  half  a  glass  of  water. 
I  also  told  him  to  dip  the  penis  in  hot  water  every  two 
hours  for  about  five  minutes  at  a  time,  and  to  wrap  the 
organ  in  gauze  saturated  with  aluminium  acetate  solution. 
For  the  threatening  swelling  in  the  groin  I  gave  him  the 
following  ointment: 

^     Ung.  hydrargyri,  5  ij 
Guaiacol,  3  ss 
Adipis,  3  vi 
M.  ft.  unguentum 
Sig.    Apply  three  times  a  day  covering  with  gauze. 

The  improvement  was  immediate  as  far  as  the  ardor 
urinae  was  concerned.  The  erections  were  also  consid- 
erably improved,  but  in  the  night  he  was  awakened  by  a 
very  painful  chordee.  "When  he  came  next  morning  the 
swelling  of  the  prepuce  was  all  gone,  and  the  meatus  was 
less  puffy  and  glazed.  The  discharge  was  abundant,  the 
urine  was  light  in  color.  I  made  no  change  in  the  treat- 
ment— told  him  to  keep  on  doing  the  same  thing  until  the 
following  morning.  I  gave  him  a  suppository  containing 
1-3  grain  of  morphine  sulphate  and  1-120  grain  of  atropine 
sulphate,  to  be  inserted  at  night  in  case  there  were  during 
the  day  any  indications  of  painful  erections.  He  did  get 
a  painful  erection  towards  evening  and  he  inserted  the  sup- 


58      GONORRHEA  AND  ITS  COIVIPLICATIONS 

pository  and  lie  slept  through  the  night  in  perfect  comfort. 
When  he  came  the  following  morning  his  condition  had 
undergone  still  further  improvement.  The  amount  of  pus 
was  less,  and  so  was  the  burning  and  the  pain  on  urina- 
tion. I  then  gave  him  an  anterior  injection  of  a  %  per 
cent,  solution  of  protargol,  and  prescribed  eight  ounces  of 
a  1/4  per  cent,  solution  of  the  same  silver  compound,  to  be 
used  regularly  every  three  hours  throughout  the  day  and 
twice  or  once  during  the  night,  the  injection  to  be  retained 
three  to  five  minutes  each  time.  I  also  prescribed  five 
minim  capsules  of  oil  of  sandalwood,  to  be  taken  four 
times  a  day.  He  came  every  day  to  the  office,  and  every 
day  I  used  either  a  protargol  (%  per  cent.)  or  a  potassium 
permanganate  (1-2000)  injection,  but  at  home  he  used  the 
protargol  solution  exclusively.  He  complained  once  or 
twice  of  burning  and  irritation  caused  by  the  injection, 
but  as  the  discharge  and  the  gonococci  kept  on  diminishing 
in  amount,  and  the  other  symptoms  kept  on  improving,  I 
did  not  consider  it  necessary  to  make  any  change.  On  the 
eleventh  day  of  treatment  the  discharge  was  reduced  to  a 
very  small  drop  in  the  morning,  and  the  gonococci  were 
scanty.  He  continued  the  injections  for  four  days  more, 
without  any  change  in  the  morning  drop.  I  then  gave  him. 
an  injection  of  zinc  sulphate  and  bismuth  subnitrate  (see 
Formulas  and  Prescriptions),  which  he  used  three  times 
a  day.  After  three  days  of  this  injection  the  drop  disap- 
peared. I  told  him  to  discontinue  all  treatment  for  three 
days  and  come  for  examination.  He  came  early  in  the 
morning,  with  the  night's  urine  in  the  bladder.  I  exam- 
ined him  and  pronounced  him  cured.  For  there  was  not  a 
trace  of  discharge,  the  meatus  was  perfectly  normal,  and 


CASE  REPORTS  59 

the  urine  was  free  from  any  traces  of  shreds.  I  expressed 
his  prostate,  and  the  secretion  was  free  from  any  gonococci. 
He  came  around  every  third  day  for  examination.  I  told 
him  to  resume  his  normal  course  of  living.  He  drank  some 
wine,  and  three  weeks  after  I  pronounced  him  cured  he 
had  intercourse,  but  no  symptoms  made  their  appearance 
and  the  urine  remained  perfectly  clear. 

Here  we  have  a  severe  case  of  acute  first  gonorrhea  cured 
in  eighteen  days.  The  patient  was  anxious  and  could  af- 
ford to  be  treated  properly.  He  could  devote  and  did 
devote  all  the  time  that  was  necessary.  Not  all  patients 
can  do  that.  Through  neglect,  insufficient  or  improper 
treatment,  the  inflammation  extends  into  the  posterior 
urethra  or  the  prostate,  and  then  it  becomes  a  matter  of 
weeks  or  months  instead  of  days.  In  this  case,  it  will  be 
noticed,  the  inflammation  at  no  time  passed  beyond  the 
anterior  urethra. 

Case  A.  B.  was  very  similar  to  A.  A.  in  its  history,  initial 
symptoms  and  course  of  the  disease.  Though  he  could  not 
attend  to  himself  so  carefully,  he  was  getting  along  nicely ; 
but  on  the  ninth  day  of  treatment  he  had  to  walk  about  a 
good  deal  on  business,  and  in  the  evening  he  "had"  to  go 
to  theater  with  some  prospective  buyers;  he  also  had  to 
treat  them  to  supper,  and  ''had"  to  drink  with  them  dif- 
ferent cocktails  and  wine.  On  the  next  day  all  his  symp- 
toms were  aggravated,  and  the  second  portion  of  the  urine 
contained  pus  and  shreds;  in  short  he  developed  an  acute 
posterior  urethritis.  I  began  to  use  instillations  of  0.5  per 
cent,  solution  of  protargol  daily,  but  the  protargol  proved  ir- 
ritating. I  diminished  the  strength  to  0.25  per  cent.,  and  it 
still  proved  irritating.     I  then  changed  to  ten  per  cent,  ar- 


60       GONORRHEA  AND  ITS  COMPLICATIONS 

gyrol,  using  two  c.c.  at  each  instillation.  After  ten  days 
very  little  progress  was  made  and  I  changed  to  albargin. 
Then  I  changed  back  to  protargol.  It  took  fifty-six  days  of 
treatment  before  I  could  pronounce  the  patient  cured.  An 
unwise  step  on  the  part  of  the  patient,  a  step  forced  by 
economic  conditions,  cost  him  several  weeks  of  extra  suffer- 
ing. 


CHAPTER  VIII 
COMMON  BACTERIAL  URETHRITIS 

While  common  bacterial  urethritis  is  not  as  frequent  nor 
as  important  as  is  gonococcal  urethritis,  still  it  is  frequent 
and  important  enough  to  deserve  special  consideration  and 
be  borne  in  mind  by  the  physician.  The  physician  who 
will  consider  every  case  of  urethral  discharge  as  gonorrhea 
will  be  correct  in  his  guess  eight  or  nine  times  out  of  ten ; 
but  in  the  other  ten  or  twenty  per  cent,  he  will  blunder, 
cause  the  patient  undue  anxiety,  prolong  the  course  of  the 
disease  unnecessarily,  throw  unjust  suspicions  in  many 
cases;  in  other  words,  be  untrue  to  his  function  as  phy- 
sician. One  of  the  first  things  for  a  physician  to  do  when 
a  patient  with  a  urethral  discharge  applies  for  treatment  is 
to  determine  the  character  of  the  discharge :  is  it  gonococcal 
or  not?  Only  after  this  point  has  been  settled,  may  the 
physician  proceed  with  treatment. 

In  the  vast  majority  of  cases  the  differential  diagnosis 
is  not  difficult.  While  exceptions  do  occur,  still  as  a  rule 
simple  bacterial  infections  of  the  urethra  are  milder  in 
their  entire  course;  the  urinary  symptoms  are  almost  en- 
tirely absent :  there  is  no  scalding  or  burning  on  urination, 
no  strangury,  no  increased  frequency.  The  discharge  may 
be  quite  abundant,  but  it  is  not  yellow  or  greenish,  but 
almost  a  pure  white ;  the  glans  is  not  swollen,  the  lips  are 
not  everted  and  puffy,  nor  eroded.     The  microscopic  ex- 

61 


62       GONORRHEA  AND  ITS  COMPLICATIONS 

amination  -Qsually  settles  the  diagnosis:  we  find  in  the 
field  numerous  bacteria  of  various  sorts,  bacilli,  cocci,  pneu- 
mococci,  bacillus  coli,  streptococci,  but  no  gonococci. 

The  causes  of  common  bacterial  urethritis  are  many. 
One  of  the  commonest  is  intercourse  with  a  woman  who  is 
the  subject  of  a  bad  leucorrhea.  And  some  intact  virgins 
may  have  the  worse  kinds  of  leucorrhea ;  worse  than  other 
women,  for  the  latter  have  recourse  to  douches,  which  are 
avoided  by  the  former  for  fear  of  rupturing  the  hymen. 
Relations  during  or  immediately  after  the  menstrual  period 
is  another  cause.  A  temporary  alteration  in  the  reaction 
or  chemical  constitution  of  the  vaginal  secretion  is  an  un- 
doubted cause.  I  have  had  a  case  of  a  man  under  treat- 
ment who  would  always  get  a  urethritis  when  he  would 
have  relations  with  his  wife  when  she  was  tired  from 
shopping  and  traveling,  or  worried  or  annoyed.  At  no 
other  time  would  he  get  any  trouble;  the  wife  was  abso- 
lutely free  from  any  leucorrhea  or  any  other  vaginal  or 
uterine  discharge.  Relations  with  a  woman  suffering  with 
an  abscess,  erosion  of  the  cervix,  or  carcinoma  may  give 
rise  to  an  obstinate  urethritis.  Another  cause  of  bacterial 
urethritis  is  auto-infection.  In  men  with  long  prepuces, 
where  smegma  is  allowed  to  accumulate,  and  a  balanitis  or 
a  phimosis  results,  the  bacteria  sometimes  wander  into  the 
urethra  and  set  up  an  inflammation  with  discharge.  An- 
other cause,  a  cause  which  fortunately  is  becoming  less  and 
less  frequent  as  the  medical  profession  and  the  laity  are 
learning  the  theory  and  practice  of  asepsis  and  antisepsis, 
is  infection  carried  into  the  urethra  with  a  sound  or  bougie. 

It  is  important  to  bear  in  mind  that  a  bacterial  urethritis 
is  often  implanted  upon  a  urethral  mucous  membrane  that 


COMMON  BACTERIAL  URETHRITIS  63 

had  been  once  the  host  of  the  gonococci,  but  is  now  entirely 
free  from  them.  That  a  man  with  a  gonorrhea  may  get  an 
additional  infection  we  know ;  but  it  is  necessary  to  bear  in 
mind  that  the  urethra  that  was  once  the  subject  of  a  gonor- 
rheal inflammation  forever  remains  a  locus  resist entiae 
minoris  and  is  more  vulnerable  to  infection  than  an  intact 
urethra.  Let  us  assume  that  A  has  had  gonorrhea  for  two 
or  three  years.  By  persistent  and  scientific  treatment  he 
is  cured  in  the  real  sense  of  the  word.  Urethroscopically 
the  mucous  membrane  is  normal,  the  severest  tests  fail  to 
bring  out  any  gonococci,  though  they  may  bring  out  a  non- 
bacterial, aseptic  discharge.  The  man  is  given  permission 
to  marry.  The  young  intact  wife  has  some  leucorrhea — 
she  has  never  used  any  vaginal  douche — there  is  excessive 
indulgence  and  the  result  is  that  the  husband  develops  a 
urethral  discharge.  He  is  frightened  to  death;  he  thinks 
his  gonorrhea  was  not  properly  cured,  that  he  has  a  relapse 
and  that  he  has  infected  his  wife.  But  a  careful  examina- 
tion shows  a  few  common  bacteria  and  no  gonococci.  Three 
or  four  injections  stop  the  discharge,  the  wife  is  ordered  a 
vaginal  douche,  and  no  further  complaints  are  heard  from 
those  quarters.  It  is  well  to  bear  in  mind  that  we  may 
have  an  unadulterated  gonorrheal  infection,  a  mixed  infec- 
tion (gonococci  plus  other  bacteria)  and  a  common  bac- 
terial infection  implanted  upon  a  previously  gonorrheal  or 
healthy  urethra. 

The  prognosis  in  simple  bacterial  urethritis  is  good ;  and 
its  course  is  usually  short,  though  if  not  treated  or  wronglj^ 
treated  it  may  become  chronic  and  extremely  obstinate.  If 
neglected  it  may  also  give  rise  to  epididymitis,  prostatitis 
and  vesiculitis,  and  these  complications  may  even  be  more 


64      GONOERHEA  AND  ITS  COMPLICATIONS 

resistant  to  treatment  than  when  occurring  as  complications 
of  gonorrhea. 

The  treatment  is  simple  and  consists  in  the  use  of  injec- 
tions of  mild  antiseptics;  potassium  permanganate,  1-3000, 
silver  nitrate  1-5000,  mercuric  chloride  1-15,000,  mercuric 
oxycyanide  1-5000,  chinosol  1-1000.  Sometimes  the  dis- 
charge disappears  completely — and  all  the  other  slight 
symptoms  with  it — after  three  or  four  injections,  and  it  is 
such  cases  that  establish  some  physician's  reputation  as  a 
great  specialist,  and  give  rise  to  the  popular  idea  that 
gonorrhea  can  be  cured  in  three  days. 

In  addition  to  the  injections,  a  mild  alkaline  diuretic 
may  be  administered. 


CHAPTER  IX 

CHANCROIDAL  URETHRITIS 

This  term  is  applied  to  an  inflammation  and  discharge 
caused  by  chancroids  within  the  urethra.  The  correct  term 
is  of  course  urethral  chancroids,  but  I  deliberately  use  the 
term  chancroidal  urethritis  to  impress  it  upon  the  phy- 
sician's mind  that  a  discharge  from  the  urethra  may  be 
something  else  than  a  gonorrhea.  While  mistaking  a  sim- 
ple bacterial  urethritis  for  gonorrhea  may  not  have  any 
dire  results,  overlooking  a  chancroid  or  chancre  within  the 
urethra  may  have  disastrous  results  for  both  patient  and 
physician.  The  physician  should  always  palpate  the 
urethra;  that  alone  will  sometimes  give  a  hint  of  the  true 
condition  of  affairs.  Then  the  pain,  whether  spontaneous, 
on  pressure,  or  on  urinating,  is  generally  localized  in  the 
anterior  urethra ;  the  discharge,  whether  profuse  or  scanty, 
is  generally  mixed  with  blood.  And  on  microscopic  exam- 
ination no  gonococci  are  found.  The  Ducrey  bacillus  is 
not  easily  identified  in  the  pus  from  urethral  chancroids. 
Buboes  are  apt  to  complicate  both  gonorrhea  and  chan- 
croid, and  as  both  gonorrheal  and  chancroidal  buboes  are 
inflammatory^  in  character  and  painful,  this  complication 
is  of  little  value  as  a  diagnostic  sign ;  except  when  we  punc- 
ture the  bubo  and  the  pus  shows  the  presence  of  the  bacillus 
of  Ducrey.  I  am  strongly  opposed  to  going  into  an  acutely 
inflamed  urethra  with  a  urethroscope,  but  in  exceptional 

65 


66       GONORRHEA  AND  ITS  COMPLICATIONS 

cases,  where  it  is  necessary  as  an  aid  to  diagnosis,  it  is 
permissible,  especially  as  chancroids  are  usually  situated 
within  the  first  inch  of  the  urethra. 

The  treatment  of  urethral  chancroids  consists  in  irrigat- 
ing the  anterior  urethra  with  normal  saline  solution,  with 
1  to  10,000  bichloride,  or  with  1  to  1000  chinosol  solution. 
After  three  or  four  days  of  this  treatment,  instillation  of 
iodoform  oil  (1  part  of  iodoform  in  20  parts  of  sterilized 
olive  oil)  10  to  20  drops  three  times  a  day,  or  the  insertion 
of  thin  and  oblong  (suppositoria  urethralia)  iodoform  sup- 
positories should  be  resorted  to : 

lodoformi,  gr.  ij 
01.  theobromae,  gr.  xij 
M.  f.  Suppos.  No.  1.     Tal.  dos.  No.  xij 
Sig.     One  t.  i.  d. 

Chancroids  within  the  urethra  are  sometimes  very  resist- 
ant to  treatment,  as  we  cannot  use  any  very  radical  meas^ 
ures;  we  cannot  cauterize  them,  as  we  can  external  chan- 
croids. 

After  the  chancroids  have  healed  it  is  sometimes  neces- 
sary to  proceed  with  prolonged  and  systematic  dilatation 
of  the  urethra,  so  as  to  prevent  the  formation  of  a  stric- 
ture, or  to  stretch  it  if  one  has  formed. 


CHAPTER  X 
SYPHILITIC  OR  CHANCRE  URETHRITIS 

That  a  chancre  can  be  situated  within  the  meatus  or  fur- 
ther in  the  urethra,  giving  rise  to  discharge,  etc.,  is  well 
known,  but  nevertheless  this  is  frequently  overlooked  by 
the  physician,  who,  as  we  said  before,  is  too  apt  to  regard 
every  kind  of  urethritis  as  gonorrheal.  If  the  possibility 
of  a  chancre  within  the  urethra  is  only  borne  in  mind,  the 
diagnosis  is  not  difficult.  The  important  points  are  the 
following.  On  palpation  a  slight  induration  or  an  indu- 
rated mass  is  felt  in  the  meatus  or  further  back  in  the 
urethra.  The  size  of  the  stream  is  diminished,  sometimes 
extremely  so,  the  lumen  may  be  almost  obliterated ;  but  the 
pain  is  slight.  The  discharge  is  usually  scanty,  and  on 
microscopic  examination  shows  the  absence  of  gonococci  but 
the  presence  of  many  blood  cells.  Inguinal  adenitis,  if 
present,  is  indolent,  painless,  non-inflammatory.  Of  course 
the  appearance  of  secondaries  or  a  positive  Wassermann 
settles  the  diagnosis,  but  their  corroborative  testimony  is 
needed  only  in  ver>'  exceptional  cases.  As  a  rule  we  can 
make  the  diagnosis  without  them. 

The  treatment  of  chancre  urethritis  or  urethral  chancre 
is  that  of  syphilis  in  general.  The  location  of  the  initial 
lesion  is  of  little  significance.  The  use  of  salvarsan,  and 
of  mercury  intramuscularly,  by  inunction  or  by  mouth  will 

result  in  the  disappearance  of  the  chancre.     But  the  heal- 

67 


68      GONORRHEA  AND  ITS  CO:\IPLICATIONS 

ing  process  may  be  expedited  by  introducing  into  tbe 
urethra  suppositories  containing  small  doses  of  mercury, 
the  most  advantageous  being  mercurial  ointment: 

Unguenti  hydrargyri,  gr.  i  (0.06) 
01.  theobromae,  gr.  x  (0.6) 
M.  f.  Suppos.  urethr.  No.  1.     Tal.  dos.  xxx 
Sig.     One  bis  vel  ter  in  die. 

Instead  of  using  cacao  butter  alone  as  a  base,  the  phar- 
macist may  be  instructed  to  add  two  or  three  grains  of 
yellow  wax  to  each  suppository,  so  that  the  prescription 
would  read: 

Unguenti  hydrargyri,  gr.  1  (0.06) 

Cerae  flavae,  gr.  ij  (0.12) 

01.  theobromae,  gr.  x  (0.6) 

M.  f .  Suppos.  urethr.  No.  1.     Tal.  Dos.  xxx 

As  the  object  of  this  book,  as  of  all  my  other  books,  is 
distinctly  utilitarian,  my  purpose  being  not  only  to  teach 
but  to  impress  the  teachings  upon  the  physician's  memory, 
I  will  report  here  a  case  of  urethral  chancre  which  was 
mistaken  and  treated  for  gonorrhea,  and  which  will  per- 
haps be  of  service  in  preventing  similar  mistakes  in  the 
future. 

X.  X.,  thirty-five  years  old,  druggist  by  profession, 
single,  has  been  leading  a  rather  loose  life,  indulging  ex- 
cessively and  promiscuously.  Had  his  first  gonorrhea  at 
the  age  of  seventeen,  and  since  then  has  had  more  relapses 
or  fresh  attacks  than  he  can  remember — probably  fifteen 
or  twenty.  However,  he  has  ceased  to  pay  much  attention 
to  them,  as  he  had  learned  to  ' '  cure ' '  his  gonorrhea  quickl}^. 


SYPHILITIC  OR  CHANCRE  URETHRITIS       69 

without  any  physician's  aid.  At  the  first  appearance  of  a 
discharge  he  would  take  some  santal  oil  capsules,  use  an  in- 
jection of  potassium  permanganate,  "finish  up"  with  zinc 
sulphate — and  in  two  or  three  weeks  he  would  be  well. 
Only  in  the  more  obstinate  attacks  he  would  consult  one  or 
another  of  the  physician  friends  who  were  in  the  habit  of 
visiting  his  drug  store. 

On  January  13  he  began  to  notice  some  difficulty  in 
urination ;  he  felt  as  if  the  stream  had  to  pass  some  obstacle. 
Two  or  three  days  later  there  was  also  some  burning  on 
urination,  which  sensation  gradually  increased.  A  rather 
profuse  discharge  also  made  its  appearance.  He  at  once 
began  to  use  potassium  permanganate  injections,  and  though 
the  injection  was  very  painful  he  persisted.  There  was 
no  diminution  in  the  discharge;  large  doses  of  oil  of  santal, 
however,  diminished  the  ardor  urmae,  and  made  the  act 
of  micturition  tolerable.  He  also  tried  copaiba  and  cubebs. 
In  about  two  weeks  he  consulted  one  of  his  general  practi- 
tioner friends,  who  looked  at  his  urethra  and  advised  him 
an  argyrol  injection.  The  result  was  nil,  and  he  con- 
sulted another  physician.  For  six  weeks  he  kept  on  using 
different  antiblenorrhagics  and  injections  for  his  gonorrhea, 
but  the  condition  was  not  only  not  improving,  it  was  get- 
ing  worse.  His  urinary  stream  was  getting  smaller  and 
smaller.  He  consulted  another  physician,  who  attempted 
to  pass  a  sound,  which  attempt  caused  severe  pain  and 
hemorrhage,  declared  he  had  a  stricture  and  dismissed  him. 
The  patient  then  consulted  me.  I  listened  to  his  history, 
looked  at  his  body,  felt  his  urethra,  his  axillary,  inguinal 
and  cubital  glands,  and  told  him  that  it  was  not  gonorrhea 
that  he  needed  treatment  for,  but  syphilis.     He  might  or 


70      GONORRHEA  AND  ITS  COMPLICATIONS 

might  not  also  be  suffering  from  a  gonorrheal  urethritis, 
but  about  his  being  the  victim  of  syphilis  in  an  active  stage, 
perhaps  in  a  virulent  form,  there  could  be  no  question. 
The  rash  on  the  body  was  unmistakable.  I  called  his  at- 
tention to  it,  and  asked  him  if  this  did  not  make  him  or 
his  physicians  suspicious.  No,  he  always  suffered  from 
pimples  (acne)  ;  he  did  speak  about  it  to  one  of  the  doc- 
tors, but  the  doctor  said  that  the  eruption  was  probably 
due  to  the  copaiba,  cubebs  and  santal  oil  that  he  was  taking. 

He  naturally  objected  to  the  diagnosis  of  syphilis,  and 
truculently  asked  if  it  was  not  possible  that  I  was  mis- 
taken. I  told  him  that  I  was  not  in  the  habit  of  declaring 
emphatically  that  a  patient  was  suffering  with  syphilis  un- 
less the  diagnosis  was  absolutely  certain;  if  there  was  one 
chance  in  a  hundred  of  a  mistake,  I  would  say:  probably 
syphilis.  But  in  his  case  there  was  no  room  for  doubt. 
Further  examination  disclosed  extensive  condylomata  lata 
and  acuminata  (which  the  patient  had  taken  for  piles), 
and  numberless  mucous  patches  in  the  mouth,  in  the 
pharynx  and  on  the  tonsils.  He  was  aware,  he  said,  that 
his  throat  was  sore,  but  as  he  had  frequently  suffered,  in 
the  winter  particularly,  from  sore  throat,  he  paid  no  atten- 
tion to  it.  The  patient  was  an  excessive  smoker,  and  not 
knowing  the  nature  of  his  trouble  he  went  on  smoking  in 
spite  of  his  mucous  patches.  The  axillary  glands  were 
considerably  enlarged,  but  the  inguinal  glands  were  only 
slightly  swollen.  The  lack  of  inguinal  adenopathy  is  a 
phenomenon  which  we  observe  not  infrequently  in  chancre 
situated  within  the  urethra. 

I  told  the  patient  that  he  was  a  danger  to  everybody  he 


SYPHILITIC  OR  CHANCRE  URETHRITIS      71 

came  in  contact  with,  to  every  customer,  to  his  relatives, 
to  the  community  at  large,  and  that  he  must  at  once  sub- 
ject himself  to  vigorous  and  persistent  treatment ;  his  uvula 
was  ulcerated  and  was  in  danger  of  dropping  off  unless 
vigorous  treatment  was  instituted  immediately.  Even 
after  these  emphatic  declarations  the  patient  was  not  quite 
convinced.  The  mind  refuses  as  long  as  possible  to  be- 
lieve things  which  are  painful.  He  asked  me  if  I  would 
not  take  a  "Wassermann  test,  just  to  make  sure.  I  said 
emphatically,  no.  To  make  a  Wassermann  would  mean 
that  I  was  not  absolutely  certain  of  my  diagnosis,  and  this 
was  not  the  case  in  his  instance.  He  went  to  another  phy- 
sician who  had  a  Wassermann  made,  and  only  when  the 
result  came  as  positive  ( -| — | — | — [- )  did  he  come  for  treat- 
ment. And  he  was  a  very  meek  patient  then.  His  uvula 
had  in  the  meantime  ulcerated  through  on  one  side,  and  as  it 
interfered  with  his  speech  and  swallowing  I  clipped  it  off. 
I  started  at  once  active  treatment.  G-ave  him  a  full 
dose  of  salvarsan,  followed  by  injections  of  mercury  every 
other  day.  There  seemed  to  be  indications  of  softening  of 
the  hard  palate,  and  as  I  feared  ulceration  I  gave  the  mer- 
cury (salicylate,  oxy cyanide  and  salicyl-arsinat^ ;  I  believe 
that  in  desperate  cases  we  get  better  results  by  frequently 
changing  the  salt  of  mercury)  in  maximum  doses.  The 
throat  and  mouth  were  sprayed  with  a  1-5000  mercuric 
chloride  solution,  and,  besides,  antiseptic  formaldehyde- 
generating  tablets  were  ordered  to  be  slowly  dissolved 
every  hour.  For  the  condylomata  a  powder  of  equal  parts 
of  resorcinol  and  calomel  was  prescribed  (a  remarkably 
efficient  application  to  all  venereal  warts)  : 


72      GONORRHEA  AND  ITS  COMPLICATIONS 

]^     Resorcinol, 

Hydrarg.  chlor.  mitis,  aa  3  ij 
M.  f .  pulvis  subtilis 
Sig.     Apply  externally. 

For  the  urethra  I  ordered  bougies  of  unguentum  hydrar- 
gyri  (0.05)  and  oleum  theobromatis  (0.8)  : 

IJ     Unguenti  Hydrargyri  U.  S.  P.,  0.05 
01.  Theobromatis,  0.8 
M.  ft.  suppos.  urethrale  No.  I 
Tales  doses  No.  XII 
Sig.     Insert  one  t.  i.  d. 

The  effect  of  the  treatment  was  immediate.  I  have  often 
said,  if  the  results  of  treatment  were  as  prompt,  as  posi- 
tive, as  clearly  apparent  in  other  diseases  as  they  are  in 
syphilis  we  would  have  no  therapeutic  nihilists,  the  anti- 
drug quacks  would  not  be  deluding  the  ignorant  and  non- 
critical  public  with  their  false  and  sophistical  statements, 
and  doctors  would  not  form  the  subject  of  satire  in  humor- 
ous, and  would-be  humorous  magazines. 

The  patient  is  of  course  still  under  treatment,  but  his 
Wassermann  taken  every  month  shows  +>  — >  <^^  H • 

I  repeat  the  fact  that  a  chancre  may  occur  within  the 
urethra  should  be  strongly  impressed  on  the  physician's 
mind.  It  would  save  him  humiliating  and  dangerous 
errors,  it  would  save  the  patient  valuable  time.  One  month 
saved  in  the  beginning  means  the  saving  of  a  year  after- 
wards. 

Tubercular  and  Neoplastic  Urethritis  need  merely  be 


SYPHILITIC  OR  CHANCRE  URETHRITIS      73 

mentioned.  They  are  very  rare,  but  it  is  well  that  the  phy- 
sician should  know  of  their  existence,  for  they  are  some- 
times the  expression  of  a  lesion  higher  up  in  the  genito- 
urinary tract. 


CHAPTER  XI 
CHEMICAL  URETHRITIS 

The  cases  of  cliemical  urethritis  are  numerous  and  well 
authenticated.  And  with  the  growing  tendency  to  self- 
medication,  to  injecting  strong  chemicals  for  the  pur- 
pose of  curing  and  preventing  gonorrhea,  they  are  becoming 
more  and  more  frequent.  I  have  reported  four  unmistak- 
able cases  of  chemical  urethritis — three  in  the  Medical  Rec- 
ord and  one  in  The  Critic  and  Guide.  As  I  consider  chem- 
ical urethritis  of  great  importance,  too  often  overlooked  or 
neglected  by  the  physician,  I  will  devote  a  little  more  space 
to  it  than  to  the  other  varieties  of  non-gonorrheal  urethritis. 
The  cases  reported  by  me  were  as  follows : 

Case  I.  Mr.  X.,  28  years  old,  was  to  be  married  on  Sep- 
tember 21,  1910.  Just  a  week  before,  September  14,  he 
considered  it  necessary  to  cohabit  with  a  prostitute.  Men 
of  a  certain  class  seem  to  regard  it  a  sacred  obligation  to 
bid  adieu  to  their  bachelorhood  in  this  dastardly  manner. 
The  temptation  is  very  great  to  break  out  in  a  tirade  against 
the  brutes,  who,  a  few  days,  sometimes  even  a  few  hours, 
before  going  to  the  marriage  bed,  will  subject  themselves 
and  their  future  wives  and  children  to  the  risk  of  infec- 
tion, because,  forsooth,  after  marriage  they  intend  to  be 
faithful  to  their  wives  and  therefore  want  to  have  a  ''last 
fling."  But  what's  the  use?  The  brutes  don't  read  medi- 
cal literature,  and  if  they  do  they  are  not  affected  by  our 

74 


CHEMICAL  URETHRITIS  75 

tirades.  And  so  Mr.  X.  had  intercourse  on  the  14th.  On 
the  16th  he  noticed,  or  thought  he  noticed,  a  tickling  in  the 
urethra.  After  a  few  hours  the  tickling  disappeared.  On 
the  17th  he  thought  it  returned.  In  view  of  the  close  ap- 
proach of  the  important  day  he  became  thoroughly  fright- 
ened— though  I  believe  there  was  nothing  the  matter  with 
him,  the  tickling  being  more  in  his  mind  than  in  his  ure- 
thra— and  consulted — a  reputable  specialist?  No;  a  drug- 
gist. This  druggist  seems  to  have  been  particularly  ig- 
norant. His  advice  to  the  patient  was  to  dissolve  one 
antiseptic  tablet  (containing  7.7  grains  of  corrosive  subli- 
mate!) in  about  half  a  glass  of  water  and  syringe  three 
times  a  day,  using  several  injections  for  each  seance. 

The  patient  did  as  told  and  syringed  out  his  urethra  four 
or  five  times  with  a  half-ounce  syringe.  This  was  before 
going  to  bed.  He  suffered  agonies  the  whole  night,  and 
the  pain  at  any  attempt  at  urination  was  so  severe  that  he 
abstained.  The  following  morning  he  applied  to  me.  The 
penis  was  four  or  five  times  its  normal  size.  The  swelling 
and  edema  were  enormous.  The  glans  was  so  puffed  that 
it  was  difficult  to  find  the  meatus.  The  patient  was  badly 
frightened,  but  constitutionally  he  was  not  ill,  no  fever, 
no  malaise,  no  stomatitis,  no  bad  odor,  in  short,  no 
symptoms  of  mercurial  poisoning.  He  showed  me  the 
tablets  which  the  druggist  had  given  him;  they  were,  as 
stated,  7.7-grain  corrosive  sublimate  tablets,  combined  with 
an  equal  amount  of  ammonium  chloride.  He  indicated  to 
me  the  amount  of  water  in  which  he  dissolved  the  tablet 
and  the  amount  was  between  four  and  six  ounces.  In  other 
words,  the  strength  of  the  bichloride  solution  which  he 
used  as  a  urethral  injection  was  about  1  in  250  to  1  in  350. 


76      GONORRHEA  AND  ITS  CO:\IPLICATIONS 

And  in  all  he  used  about  three  grains  of  corrosive  subli- 
mate; but,  of  course,  he  let  the  injection  run  right  out. 
That  there  were  no  systemic  symptoms  I  ascribe  to  the  fact 
that  the  strength  of  the  solution  by  necrosing  the  mucous 
membrane  prevented  the  absorption  of  the  poison;  the 
effects  therefore  were  purely  local.  That  his  bladder  was 
apparently  not  injured,  I  ascribe  to  the  fact  that  he  in- 
jected gently  and  did  not  force  open  the  shut-off  muscle. 
He  tried  to  urinate  unaided,  but  failed.  I  then  with 
great  difficulty  anesthetized  the  urethra,  passed  a  small 
catheter,  and  withdrew  twenty-two  ounces  of  urine.  The 
patient  at  once  felt  relieved.  For  the  penis  I  ordered 
compresses  of  liquor  alumini  acetatis  (Burrow's  solution)  ; 
to  do  away  with  the  strangury  I  ordered  rectal  supposi- 
tories of  morphine  sulphate  (gr.  i/4)  and  atropine  sulphate 
(gr.  1-60)  ;  also,  internally  a  mixture  of  potassium  bro- 
mide, potassium  acetate,  arbutin,  and  fluid  extract  of 
triticum;  also  to  drink  frequently  of  a  cold  infusion  of 
linseed.  This  treatment  improved  the  patient's  condition 
at  once.  The  swelling  went  down  considerably;  the  pain 
and  burning  on  urination  disappeared  almost  entirely. 
But  on  the  next  day  a  profuse  thin  discharge  made  its  ap- 
pearance and  the  urine  contained  numerous  flocculi.  The 
patient  was,  of  course,  sure  he  had  gonorrhea,  but  I  was 
convinced  of  the  contrary.  Numerous  examinations  failed 
to  disclose  a  single  gonococcus  or  a  gonococcus-like  dip- 
lococcus.  It  was  pure — one  might  say  chemically  pure — 
pus,  caused  by  an  irritating  antiseptic.  I  used  no  local 
treatment  whatever — only  internal  demulcents  and  mild 
diuretics,  and  the  discharge  gradually  diminished;  it  is 
now  reduced  to  the  fraction  of  a  drop  in  the  morning, 


CHEMICAL  URETHRITIS  77 

simulating  the  morning  drop  of  gonorrhea,  and  the  urine 
contains  floeeuli ;  they  are,  however,  entirely  different  from 
Tripperfaden  and  they,  as  well  as  the  minute  discharge, 
are  entirely  free  from  cocci.  The  wedding,  which  was 
necessarily  delayed  for  a  month,  is  to  take  place  in  a  few 
days  and  I  have  no  hesitancy  in  giving  him  my  unquali- 
fied permission.*  During  one  period  in  the  treatment 
there  seemed  to  be  a  tendency  to  the  formation  of  stricture, 
but  several  dilatations  with  Kollmann's  dilator,  followed 
by  the  instillation  of  a  1  per  cent,  solution  of  thymol  iodide 
in  oil,  restored  the  urethra  to  its  normal  caliber,  and  it  is 
now  perfectly  normal  in  this  respect. 

Case  II.  This  case  concerns  a  young  man  who  was  suf- 
fering with  too  frequent  nightly  emissions  and  who  weis 
advised  to  use  an  injection  of  zinc  sulphate  as  a  remedy. 
The  prescription  called  for  zinc  sulphate,  2  drams;  water, 
1  pint.  After  using  this  injection  for  two  weeks  he  no- 
ticed a  slight  thin  discharge;  he  thought  this  was  semen 
(!),  and  increased  the  frequency  of  the  injections.  The 
discharge  then  increased,  becoming  thicker,  according  to 
his  statement.  He  then  went  to  a  physician,  and  in  spite 
of  telling  him  the  history  of  the  case,  in  spite  of  assuring 
him  that  he  had  never  had  intercourse  in  his  life,  the  doc- 
tor proceeded  to  treat  the  case  as  one  of  gonorrhea.  (We 
are  sometimes  too  ready  to  consider  our  patients  liars.) 
He  never  examined  the  discharge,  but  gave  him  the  regu- 
lation treatment  of  copaiba  and  saxital  oil  internally  and 

*  The  patient  was  married  on  Xov ember  1 ;  on  the  18th  he  reported 
himself  as  perfectly  well,  and  an  examination  failed  to  disclose  any 
pathological  condition,  except  that  the  urine  still  contained  a  few 
small  sterile  floeeuli. 


78       GONORRHEA  AND  ITS  COMPLICATIONS 

potassium  permanganate  as  an  injection;  later  on  he 
changed  the  potassium  permanganate  to  an  organic  silver 
preparation.  Under  this  treatment  the  case  was  getting 
gradually  worse,  the  discharge  was  increasing  and  so  were 
the  nightly  pollutions,  and  what  is  worse,  the  patient  devel- 
oped a  stricture.  When  he  applied  to  me  for  treatment 
the  discharge  was  thin,  but  profuse,  and  no  gonococci  what- 
ever, after  numerous  and  repeated  examinations  could  be 
found.  About  2%  inches  from  the  meatus  there  was  a 
stricture,  which  permitted  the  passage  with  some  difficulty 
of  18  F.  I  told  him  to  discontinue  all  treatment  for  ten 
days  and  present  himself  at  the  end  of  that  period.  He 
did.  His  discharge  had  diminished  materially,  being  only 
a  few  drops  in  the  morning  and  practically  nothing  during 
the  day.  I  then  began  to  dilate  his  stricture,  which 
yielded  completely  to  twelve  dilatations.  The  only  other 
local  treatment  I  gave  him  was  the  instillation  of  a  dram 
of  a  1  per  cent,  solution  of  thymol  iodide  in  olive  oil.  The 
stream  of  urine  became  normal,  the  discharge  disappeared, 
with  the  exception  of  a  minute  drop  in  the  morning,  which 
also  finally  yielded  to  small  anterior  injections  of  5  per  cent, 
alcohol  (alcohol  U.  S.  P.  1  part,  distilled  water  19  parts). 
I  have  not  seen  the  use  of  alcohol  as  a  remedy  against  ure- 
thral discharges  mentioned  anywhere,  but  it  has  rendered 
me  good  service  in  some  very  obstinate  cases.  In  some  in- 
stances I  use  it  10  to  20  per  cent,  strong  and  even  stronger. 
Case  III.  The  third  case  was  one  of  what  I  call  silver- 
nitrate  urethritis,  of  which  thousands  and  thousands  of 
cases  walk  the  land,  and  I  report  it,  not  because  of  its 
rarity,  but  because  of  its  commonness,  in  order  to  call  at- 
tention as  forcibly  as  I  can  to  a  form  of  malpractice  very 


CHEMICAL  URETHRITIS  79 

prevalent  in  our  profession;  well-intentioned  malpractice, 
but  malpractice,  nevertheless.  I  refer  to  the  custom, 
handed  down  to  us  from  former  decades,  of  "testing"  the 
reality  and  permanence  of  a  gonorrheal  cure  by  injecting 
into  the  urethra  a  strong  solution  of  silver  nitrate.  And 
if  there  is  anything  I  am  convinced  of  in  the  handling  of 
genitourinary  cases  it  is  that  many  a  cured  case  of  gonor- 
rhea may  become,  by  repeated  injections  of  silver  nitrate, 
converted  into  a  rebellious  or  practically  incurable  case  of 
chemical  or  bacterial  urethritis.  In  the  early  days  of  my 
practice  I  was  gaiilty  of  the  same  practice  and  more  than 
once  have  I  injected  a,  to  all  intents  and  purposes,  cured 
case  of  gonorrhea — no  discharge,  no  gonococci,  no  shreds 
— only  to  have  the  patient  come  back  with  an  obstinate  dis- 
charge, which  it  took  weeks  and  often  months  to  cure ;  and 
after  each  ''testing"  the  discharge  was  less  and  less  amen- 
able to  treatment.  And  I  state  it  as  my  positive  opinion  that 
thousands  of  people  are  walking  the  earth  with  urethral 
discharges  which  were  caused  by  assaulting  the  urethra, 
weakened  by  gonorrheal  infection,  with  an  irritant  chemi- 
cal, and  who  would  have  remained  perfectly  well  if  their 
urethra  had  not  been  subjected  to  any  such  heroic  tests. 
The  late  Lassar  was  the  only  one  of  the  "big"  men  whom 
I  heard  condemning  the  silver  nitrate  test  in  most  un- 
equivocal language.  I  trust  that  these  lines  may  have  the 
effect  of  inducing  some  colleagues  to  discard  the  test  alto- 
gether, or,  at  least,  to  be  very  cautious  and  mild  in  its 
application. 

This  case  is  a  clear-cut  case  of  silver  nitrate  urethritis. 
Mr.  0.,  22  years  old,  noticed  a  urethral  discharge  on  May 
22,  1908.    It  was  the  first  time  he  ever  had  any  trouble. 


80      GONORRHEA  AND  ITS  COIMPLICATIONS 

He  came  to  me  for  treatment  May  23.  Examination 
showed  the  presence  of  numerous  gonococci.  Under  the 
treatment  the  discharge  completely  disappeared  in  three 
weeks.  I  kept  him  under  observation  for  three  wrecks 
more  and  then  discharged  him  cured.  I  use  the  word 
cured,  because  contrary  to  the  opinion  of  some  urologists, 
I  believe  that  gonorrhea  can  be  as  perfectly  and  as  radi- 
cally cured  as  many  other  diseases,  say  chancroids,  or 
eczema,  or  scabies.  There  was  absolutely  no  discharge ;  the 
urine  was  clear  of  shreds,  the  expressed  secretions  from 
the  prostate  and  the  sediment  from  the  centrifugalized 
urine  showed  no  gonococci,  and  I  told  him  that  I  consid- 
ered him  perfectly  cured.  I  felt  especially  justified  in 
doing  this,  because  at  no  time  were  there  any  symptoms 
of  posterior  involvement  and  I  felt  sure  that  the  infection 
was  all  the  time  limited  to  the  anterior  portion.  To  the 
question  whether  he  could  marry  safely,  I  replied  in  the 
affirmative.  *'But,"  I  said,  *'if  you  want  to  feel  at  per- 
fect ease,  come  a  month  or  so  before  you  intend  to  get 
married  and  I  will  give  you  again  a  thorough  examina- 
tion." And  this  was  the  last  I  saw  or  heard  of  him  until 
October,  1909.  He  became  engaged  in  the  spring  of  that 
year  and  the  wedding  was  to  take  place  in  September. 
Early  in  August  he  called  at  my  office  to  be  examined,  but 
was  told  that  I  was  away  in  Europe  and  would  not  return 
until  the  beginning  of  October.  He  then  went  to  another 
physician,  to  whom  he  told  the  entire  history  of  the  case. 
And  he  also  told  him  that  I  considered  him  perfectly  cured 
and  he  considered  so  himself,  because  during  the  thirteen 
or  fourteen  months  his  urine  had  been  perfectly  clear  and 
he  had  no  symptoms  of  any  kind. 


CHEMICAL  URETHRITIS  81 

The  doctor  proceeded  to  apply  the  beer-silver  test. 
Though  the  patient  was  not  a  beer  drinker  and  detested 
beer,  he  was  told  to  drink  several  glasses  of  beer  for  three 
evenings  in  succession.  This  produced  absolutely  no  effect. 
The  doctor,  however,  was  not  satisfied  with  this  test,  but 
proceeded  to  inject  silver  nitrate.  I  never  could  find  out 
what  the  strength  of  the  solution  was,  but  the  patient  said 
that  the  pain  was  intense,  and  several  hours  later  the  ure- 
thra began  to  discharge.  This  was  taken  by  the  doctor 
as  positive  proof  of  gonorrhea,  which  he  proceeded  to  treat. 
He  treated  the  patient  both  internally  and  by  injections, 
and  he  treated  him  very  vigorously.  But  when  he  came  to 
me  two  months  later,  in  October,  his  discharge  was,  ac- 
cording to  his  statement,  worse  than  ever.  I  subjected  the 
discharge  to  numerous  examinations,  all  of  which  were 
negative  as  far  as  the  gonococcus  was  concerned.  I  discon- 
tinued all  treatment  for  a  month,  with  the  exception  of 
advising  him  hot  sitz-baths.  The  discharge  had  diminished 
by  the  end  of  that  period,  but  it  was  slow  work  to  stop 
the  discharge  entirely;  it  took  five  months  before  I  could 
pronounce  him  cured.  Examinations  for  gonococci,  under- 
taken at  different  periods,  all  proved  negative. 

Here  a  man  had  to  suffer  pain,  annoyance,  anguish,  and 
great  expense  for  seven  months  as  a  tribute  to  an  old  brutal 
test  handed  down  to  us  by  sanctified  tradition  and  ac- 
cepted by  us  without  criticism,  without  analysis.  There 
are  only  too  many  such  cases.  And  if,  as  is  often  the  case, 
a  bacterial  infection  becomes  implanted  on  the  originally 
sterile  discharge,  then  we  have  to  deal  with  a  bacterial  ure- 
thritis, which  is  sometimes  more  rebellious  to  treatment 
than  a  simple  gonorrheal  urethritis. 


82       GONORRHEA  AND  ITS  COMPLICATIONS 

Case  IV.  The  patient,  a  prominent  member  of  the  phar- 
maceutical profession,  contracted  gonorrhea  six  years  ago. 
As  he  was  a  clever  man  in  pharmacy,  his  papers  being 
sought  by  the  pharmaceutical  journals  and  pharmaceutical 
associations,  he  thought  he  was  also  clever  in  venereology. 
He  treated  himself  with  argyrol,  protargol,  potassium  per- 
manganate, zinc  sulphate,  bismuth  subnitrate,  Lloyd's 
hydrastis,  hydrogen  peroxide,  etc.,  locally,  and  with 
santal  oil  and  its  various  combinations  internally.  And 
mirabile  dictu  in  about  fourteen  weeks  he  was  cured.  That 
is,  he  thought  he  was.  He  had  no  discharge,  and  this  to 
his  mind  Was  the  proof  that  the  gonorrhea  was  cured ;  this 
pernicious  idea  still  lurks  in  the  minds  of  the  laity,  and  un- 
fortunately also  in  the  minds  of  many  country  and  not  a 
few  city  physicians.  Every  four  to  six  months,  however, 
he  would  notice  again  a  slight  discharge,  which  he  would 
ascribe  to  a  fresh  infection.  But  as  he  would  ''cure"  it 
each  time  with  a  few  injections  of  zinc  sulphate  and  potas- 
sium permanganate,  he  attached  no  importance  to  these 
attacks  and  used  no  precautionary  measures  or  prophylac- 
tics. During  one  of  those  attacks  he  injected  himself 
rather  forcibly,  or  perhaps  the  syringe  was  not  aseptic, 
and  he  was  laid  up  for  three  weeks  with  a  severe  epid- 
idymitis. He  was  then  treated  by  a  competent  physician, 
and  when  he  got  well  of  the  epididymitis  he  continued  to 
treat  himself  without  a  doctor — for  about  six  months — ^until 
he  was  all  well — according  to  his  statement.  That  is,  his 
urine,  which  always  contained  shreds,  cleared  up  almost 
perfectly,  showing  only  a  few  small  flocculi.  Repeated 
examinations  by  a  bacteriological  laboratory  showed  ab- 
sence   of   gonoeocci;    whether   the   examinations   in   those 


CHEMICAL  URETHRITIS  83 

laboratories  are  always  eondncted  with  the  painstaking 
care  and  attention  to  all  minutiae  that  such  examinations 
demand,  I  do  not  know,  but  all  the  reports  he  brought  with 
him  stated:  gonococci  not  found. 

He  remained  apparently  well  up  to  about  eight  months 
ago.  Once  in  a  while  he  would  feel  a  little  moisture  about 
the  meatus,  either  spontaneously  or  after  micturition  or 
defecation.  It  is  my  opinion  that  this  was  nothing  but  a 
little  secretion  of  mucus  from  the  urethral  glands,  or  per- 
haps some  prostatic  fluid.  Eight  months  ago  he  became 
engaged,  and  then  the  little  moisture  increased  in  amount, 
and  was  more  frequently  in  evidence.  Again  it  is  my 
opinion  that  it  was  an  innocent  affair — a  slight  urethror- 
rhea  or  prostatorrhea  is  not  a  rare  phenomenon  in  engaged 
men.  But  he  became  annoyed,  thought  it  was  his  old  gleet, 
and  decided  to  cure  it  himself.  He  inquired  of  a  physician, 
what  was,  in  his  opinion,  the  best  treatment  for  chronic 
gleet  and  the  doctor  told  him  that  as  far  as  he  knew,  deep 
instillations  of  a  five  to  ten  per  cent,  solution  of  silver 
nitrate  gave  the  promptest  and  best  results.  Glad  of  the 
information,  our  friend  secured  a  4  dram  syringe  and 
filled  it  with  a  ten  per  cent,  solution  of  silver  nitrate.  The 
very  clever  druggist,  clever  in  his  own  line,  did  not  know 
the  difference  between  instillations  and  injections.  He 
held  in  the  injection  for  about  five  minutes,  in  spite  of  the 
fact  that  the  pain  was  acute.  There  was  immediate  stran- 
gury, and  in  spite  of  his  repeated  painful  efforts  to  urinate 
he  was  unable  to  do  so.  About  ten  hours  after  the  injec- 
tion, the  pain,  strangury,  desire  and  inability  to  urinate 
became  excruciating  and  he  applied  to  a  physician,  who 
catheterized  him  after  much  effort.     He  was  ordered  mor- 


84       GONORRHEA  AND  ITS  COMPLICATIONS 

phine  and  atropine  suppositories,  potassium  citrate  and 
fl.  ex.  hyoscyamus  internally,  and  hot  baths.  This  im- 
proved the  condition  somewhat,  but  the  following  morning 
he  woke  up  with  an  abundant  purulent  and  sanioiis  dis- 
charge, and  the  urine  •  contained  much  debris  and  large 
shreds.  Micturition  was  painful  and  frequent.  He  con- 
sulted three  physicians  in  rapid  succession,  but  expecting 
too  rapid  results,  he  was  too  impatient  to  use  the  prescribed 
treatment  faithfully  and  systematically.  After  six  or 
seven  weeks  of  desultory  treatment  he  applied  to  me.  I 
found  no  gonococci,  the  discharge  was  practically  sterile, 
but  I  found  several  strictures  of  large  caliber.  I  explained 
to  him  his  condition.  I  told  him  that  he  was  suffering 
from  chemical,  in  his  case,  silver  nitrate  urethritis,  and  I 
impressed  upon  his  mind  that  if  he  expected  a  rapid  cure 
he  should  seek  another  physician,  that  I  was  not  a  cure- 
quick  doctor.  Many  patients  need  a  talking  to  right  at 
the  start.  It  clears  the  atmosphere,  and  teaches  them  not 
to  be  impatient  and  not  to  expect  miracles.  My  patient 
became  very  docile,  admitting  that  the  proverb  that  he 
who  treats  himself  has  a  fool  for  a  patient  was  even  truer 
than  the  one  used  about  lawyers,  and  he  followed  instruc- 
tions religiously.  The  treatment  consisted  principally  in 
passing  sounds  and  Kollmann's  dilators  and  in  instilla- 
tions and  injections  of  sterilized  solutions  of  aristol  or 
europhen  in  olive  oil.  After  four  months'  treatment 
twice  a  week  at  first,  and  once  a  week  toward  the  end,  I 
was  able  to  discharge  him  cured. 

I  wish  to  emphasize  the  following  points : 

1.  Urethritis  of  chemical  origin  is  more  common  than  is 
generally  supposed. 


CHEMICAL  URETHRITIS  85 

2.  While  most  cases  are  caused  from  self-administered 
injections  prescribed  by  barbers,  friends,  and  others,  some 
cases  owe  their  origin  to  the  over-zealousness  of  physicians. 

3.  The  unscientific  and  unjustifiable  test  of  injecting 
strong  solutions  of  silver  nitrate,  which  should  be  forever 
discarded,  has  been  responsible  for  very  many  cases  of 
chemical  urethritis. 

4.  The  diagnosis  of  chemical  urethritis  is  made  by  the 
history  of  the  case,  the  freedom  of  discharge  from  gono- 
cocci  and,  generally,  its  improvement  on  being  let  alone. 

TREATMENT 

The  treatment  of  chemical  urethritis  has  been  outlined 
fully  in  the  reports  of  the  cases.  I  merely  wish  to  em- 
phasize that  one  of  the  most  useful  agents  in  the  treatment 
is  warm  sterilized  olive  or  almond  oil,  or  a  %  to  1  per  cent, 
solution  of  some  organic  iodine  derivative  (iodoform, 
dithymoliodide,  europhen)  in  one  of  the  above  oils. 

Tendency  to  stricture  should  be  prevented  by  dilators  or 
by  sounds  dipped  in  the  just  referred  to  solutions. 


CHAPTER  XII 

PROPHYLACTIC  URETHRITIS 

Apparently  there  is  no  good  without  some  attending  evil. 
Almost  every  reform,  every  sanitary  measure,  is  accom- 
panied with  some  undesirable,  often  unexpected  and  un- 
looked  for  results.  The  writer,  as  the  readers  of  his  works 
undoubtedly  know,  has  been  one  of  the  earliest,  strongest 
and  most  persistent  advocates  of  individual  venereal  pro- 
phylaxis. Venereal  disease,  whether  gonorrhea  or  syphilis, 
is  such  a  terrible  calamity  that  every  measure  that  will 
reduce  the  danger  of  infection  is  to  be  supported  vigor- 
ously, to  be  advocated  energetically.  And  the  fact  that 
venereal  prophylactics  are  beginning  to  be  used  quite  com- 
monly is  to-  be  considered  as  a  sign  of  progress,  as  a  dis- 
tinct gaiQ  in  our  fight  with  the  venereal  scourge.  But  I 
always  feared,  nay  I  felt  certain,  that  its  initial  use  would 
be  followed  by  some  undesirable  features.  There  was  un- 
deniable danger  that  some  men,  feeling  over-secure,  would 
rush  into  places  from  which  they  would  keep  away  other- 
wise; others,  with  contempt  bred  of  familiarity,  seeing 
that  they  indulged  for  years  without  any  mishap,  would 
become  careless  and  would  apply  the  prophylactic  in  a 
neglectful  and  perfunctory  manner — and  then  there  would 
be  trouble  and  they  would  swear  at  the  prophylactic  and  its 
advocates.     Others,  over  conscientious  and  overscrupulous, 

would  use  too  much  of  the  prophylactic  or  would  use  an 

86 


PEOPHYLACTIC  URETHRITIS  87 

extra  strong  one,  and  then  there  would  be  trouble  again, 
though  of  a  different  character.  And  it  is  to  this  last 
trouble  that  I  am.  referring  in  this  chapter,  because  during 
the  past  year  I  have  met  with  several  cases  of  urethritis 
and  penile  irritation  which,  somewhat  puzzling  at  first, 
were  later  shown  to  have  been  due  to  the  improper  use  of 
the  prophylactic  or  to  the  use  of  an  improper  prophylactic. 
I  have  therefore  applied  to  this  form  of  urethral  and  penile 
inflammation  the  term  of  prophylactic  urethritis,  and  pro- 
phylactic balaidtis  or  balano-posthitis,  respectively,  as 
the  case  may  be.  In  reality,  however,  it  is  merely  a  variety 
of  chemical  urethritis. 


CHAPTER  XIII 

TRAUMATIC  URETHRITIS 

Tranniatic  urethritis  results  from  injuries  to  the  mucous 
membrane  of  the  urethra  produced  by  foreign  bodies  in- 
troduced into  the  canal.  The  foreign  bodies  are  usually 
introduced  for  purposes  of  masturbation,  and  among  the 
commonest  are  lead  pencils,  slate  pencils,  penholders, 
matches,  sticks  of  wood,  smooth  or  deliberately  roughened, 
etc..  etc.  Of  course  the  urethritis  is  rarely  due  to  the 
trauma  alone,  but  to  the  trauma  plus  infection:  the  in- 
jured and  abraded  mucous  membrane  is  a  favorable  soil 
for  the  development  of  various  micro-organisms.  (The 
urethritis  following  the  frequent  or  permanent  use  of  a 
catheter  is  generally  more  due  t-o  infection  than  to  trau- 
matism.) The  diagnosis  of  the  case  is  of  course  easily 
made  by  the  history.  But  in  such  cases  patients  are  apt 
to  lie,  on  account  of  shame,  and  then  the  character  of  the 
discharge  and  an  endoscopic  examination  will  be  of  aid. 
The  treatment  consists  in  mild  antiseptic  injections  or 
irrigations  (]x)ric  acid  1  per  cent.,  saline  solution  7  to  1,000, 
potassium  permanganate  1  to  3.000,  chinosol  1  to  1,000, 
solution  of  europhen  in  oil,  5  per  cent.,  etc.)  and  in  the 
administration  of  oil  of  sandalwood  and  hexamethylene. 
But  after  the  discharge  and  all  other  signs  of  inflamma- 
tion have  subsided  we  should  carefully  examine  the  ure- 
thra for  any  strictures.  For  traumatic  urethritis  is  very- 
apt  to  give  rise  to  strictures,  and  if  any  are  found  they 

should  be  dilated  by  sounds  or  Kollmann's  dilators. 

88 


CHAPTER  XIV 

TOXIC  URETHRITIS 

An  inflammation  of  the  uretlira  may  result  from  the 
intake  of  poisonous  or  irritating  substances,  or  even  from 
certain  foods  against  which  the  particular  individual  has 
an  idiosyncrasy.  One  of  the  worst  or  rather  most  painful 
cases  of  urethritis  that  I  have  ever  had  to  treat — ^it  was  in 
the  early  days  of  my  practice — was  in  a  policeman  who 
took  at  one  dose  a  teaspoonful  of  cantharides  together  with 
an  ounce  of  tincture  of  capsicum  and  an  ounce  of  tincture 
of  zingiber.  The  mixture  was  recommended  to  him  as  an 
infallible  aphrodisiac,  and  as  he  wanted  to  make  a  good 
showing  he  took  it  all.  He  soon  however  got  such  a  severe 
burning,  strangury  and  priapism  that  he  was  unable  to 
have  any  relations  at  all,  and  in  the  morning  he  had  a 
sero-sanguinolent  discharge  and  urination  was  extremely 
painful.  The  condition  was,  however,  relieved  in  a  few 
hours,  and  in  three  or  four  days  he  was  well.  That  some 
people  get  a  urethral  discharge  after  drinking  three  or 
four  glasses  of  beer  is  well  known,  but  this  takes  place 
only  in  urethras  that  have  been  afflicted  with  gonorrhea- 
It  does  not  mean  in  all  cases  that  the  gonorrhea  is  not  yet 
cured.  The  gonorrhea  may  be  "absolutely"  cured,  that  is 
we  may  not  under  any  circumstances  be  able  to  get  any 
gonococci,  and  the  complement  fixation  test  may  be  nega- 
tive; but  the  urethral  mucous  membrane  has  a  low  resist- 

89 


90       GONORRHEA  AND  ITS  COMPLICATIONS 

ing  power  and  tlie  irritation  produced  by  the  beer  is  suf- 
ficient to  call  out  a  discharge.  Potassium  nitrate  (niter) 
in  very  large  doses,  one-half  to  one  ounce,  may  cause  a 
slight  discharge  in  a  previously  damaged  urethra.  I  had 
such  a  case  in  a  man  who  had  had  several  attacks  of  gonor- 
rhea. But  the  drugs  above  enumerated  are  about  the  only 
ones  which  may  in  very  large  doses  cause  a  urethritis  in 
susceptible  or  previously  damaged  urethras.  The  state- 
ment that  a  urethritis  may  follow  the  ingestion  of  cress, 
asparagus,  strawberries,  etc.,  must  be  taken  with  a  grain 
of  salt.  Of  course  everything  is  possible,  but  I  would  have 
to  be  very  sure  of  my  patients  before  I  would  accept  such 
an  etiology. 

The  treatment  of  toxic  urethritis  is  obvious:  bland 
drinks  and  diuretics :  linseed  tea,  sodium  citrate,  tincture 
of  hyoscyamus,  small  doses  of  oil  of  sandalwood.  Sup- 
positories of  opium  and  belladonna  or  morphine  and  atro- 
pine may  be  necessary.  No  injections  need  be  used.  The 
diet  should  be  light  and  bland  (no  spices),  no  coffee  or 
tea  or  carbonated  water,  but  plenty  of  milk  and  plain 
water. 

Diathesic  Urethritis.  The  older  writers  believed  that  a 
urethritis  may  occur  as  a  result  of  rheumatism,  gout  or 
diabetes.  I  do  not  deny  this  possibility,  but  I  believe  that 
a  modern  careful  examination  would  show  such  cases  to 
be  of  simpler  origin:  a  microbic  origin  would  be  revealed. 
A  profuse  urethral  discharge  may  also  occur  in  the  course 
of  pneumonia  or  typhoid ;  but  here  also,  I  believe,  we  have 
to  deal  with  the  exacerbation  or  awakening  of  a  dormant, 
semi-cured  gonorrhea. 


CHAPTER  XV 

URETHRITIS  FROM  EXCESS  AND 
MASTURBATION 

We  are  told  that  urethritis  may  occur  from  excessive 
sexual  intercourse,  from  excessive  unsatisfied  libido  and 
from  excessive  masturbation.  That  this  may  occur  in  a 
urethra  which  has  been  weakened  by  a  previous  gonorrhea 
— even  if  the  gonorrhea  be  entirely  cured — I  admit.  But 
that  it  may  take  place  in  an  intact  urethra,  I  deny.  It  is 
not  wise  to  be  dogmatic  about  anything  in  medicine,  and 
I  would  therefore  change  the  phrase  "I  deny''  to  "I 
strongly  doubt."  I  have  now  under  treatment  a  mastur- 
bator,  who  has  been  masturbating  for  twenty  years;  he 
will  not  masturbate  for  months  at  a  time,  but  when  he  once 
yields,  he  will  masturbate  10,  15  and  20  times  a  day.  In 
the  last  few  acts  just  a  few  drops  of  a  thin  fluid  will  come 
out — ^not  at  all  like  semen — and  he  will  be  completely  ex- 
hausted. But  he  has  never  developed  any  trace  of  dis- 
charge, though  his  urine  contains  a  few  small  shreds  from 
the  posterior  urethra,  as  that  of  most  masturbators  does. 

I  have  had  persons  under  treatment  who  made  perfect 

beasts  of  themselves  in  intercourse  (no,  this  is  unjust  to 

the  beasts,  as  they  never  overdo  it) .     Some  men  have  been 

in  the  habit  of  performing  the  act  so  many  times  during 

one  night,  that  in  the  last  acts  only  a  sanguinolent  fluid 

would  issue.    And  still  they  did  not  develop  any  urethritis. 

91 


92       GONORRHEA  AND  ITS  COMPLICATIONS 

I  therefore  must  deny  the  probability  if  not  possibility  of 
urethritis  from  excess  per  se. 

Ricord  relates  the  case  of  a  physician  who  had  had  no 
intercourse  for  six  weeks  and  then  passed  the  entire  day 
from  10  in  the  morning  to  7  at  night  with  a  woman  whom 
he  loved.  He  desired  to  have  relations  with  her,  he  was  in 
a  state  of  continuous  excitement,  but  he  was  unable  to 
overcome  her  resistance.  His  excitement  was  therefore 
not  allayed,  and  three  days  later  he  developed  a  painful 
urethritis.  We  do  not  know  however  the  previous  history 
of  that  doctor's  urethra,  and  Ricord 's  case  is  therefore  not 
conclusive.  That  long,  ungratified  excitement  will  induce 
a  congestion  of  the  posterior  urethra  is  well  known,  but 
between  congestion  and  inflammation  there  is  quite  a  gap. 


CHAPTER  XVI 

THE  WIDELY  VARYING  CONDITIONS 
KNOWN  AS  CHRONIC  GONORRHEA 

Before  we  proceed  to  outline  the  treatment  of  chronic 
gonorrhea  a  few  preliminary  remarks  are  very  essential.  A 
vast  conglomeration  of  greatly  varying  conditions  are  com- 
prised under  the  term  chronic  gonorrhea.  While  when  we 
say  Acute  Gonorrhea,  or  Acute  Gonorrheal  Urethritis,  we 
refer  to  a  distinct  and  definite  entity,  this  is  not  true  of  the 
term  chronic  gonorrhea  or  chronic  gonorrheal  urethritis. 
In  fact  so  confused  and  indefinite  is  the  etiology,  pathology 
and  symptomatology  of  chronic  gonorrhea  that  we  need  not 
treat  it  as  a  separate  entity,  and  can  speak  of  it  simply  as 
chronic  urethritis. 

And  it  will  be  seen  that  while  I  treated  the  various  forms 
of  acute  urethritis  under  separate  heads,  I  do  not  do  so  in 
the  case  of  the  chronic  forms  of  urethritis,  but  treat  them 
all  together  under  one  head;  because,  whether  a  chronic 
urethritis  be  due  to  the  gonococcus  or  to  another  germ  (it 
is  generally  a  mixed  infection)  or  to  a  non-bacterial  cause 
the  treatment  is  practically  the  same. 

To  show  how  widely  varying  in  every  one  of  their  ele- 
ments— etiology,  pathology,  symptomatology  and  prognosis 
— are  the  conditions  which  go  under  the  name  chronic 
gonorrhea,  we  will  briefly  present  a  few  cases : 

Case  I.  Man  has  had  gonorrhea  for  eighteen  months. 
Has  been  treated  in  the  approved  fashion  almost  without 

93 


94       GONORRHEA  AND  ITS  COIMPLICATIONS 

interruption  since  the  first  day  the  discharge  showed  itself. 
The  urine  is  clear ;  there  are  no  shreds ;  only  in  the  morning 
the  meatus  is  glued  together.  By  strong  expression  a  very 
minute  amount  of  moisture,  hardly  enough  to  be  called 
secretion,  is  expressed.  A  smear  from  this  secretion  is 
perfectly  sterile.  Still  the  man  is  worried  and  is  developing 
neurasthenic  symptoms  on  account  of  the  persistency  of 
that  little  moisture.  I  suspect  that  the  trouble  is  due  to 
over-treatment,  suspend  all  treatment,  tell  him  to  live  his 
normal,  regular  life  and  partake  moderately  of  beer  and 
wine  as  he  used  to.  In  a  week  the  meatus  becomes  normal 
and  there  is  no  further  moisture  or  s'eoretion,  and  after  a 
thorough  test  the  case  is  pronounced  cured. 

Case  2.  Similar  to  Case  1,  except  that  there  is  a  good- 
sized  ''morning  drop."  In  the  daytime  no  secretion  of 
any  kind,  the  meatus  perfectly  dry.  No  gonococci.  I  sus- 
pect that  the  morning  drop  is  kept  up  by  the  silver  nitrate 
irrigations  and  instillations  which  he  has  been  receiving 
two  or  three  times  a  week.  I  stop  those  and  order  a  3  per 
cent,  zinc  sulphate  solution  injected  twice  a  day,  after  three 
days  to  be  injected  only  once  a  day.  In  about  a  weerk  the 
discharge  disappears  and  the  patient  is  quite  well. 

Case  3.  Had  gonorrhea  for  about  eight  months.  No 
symptoms  now  except  a  little  minute  amount  of  discharge  in 
the  morning  and  throughout  the  day.  Numerous  smears 
show  the  absence  of  gonococci.  The  urine  is  slightly  turbid. 
A  urethroscopic  examination  shows  a  practically^  normal 
mucous  membrane,  no  localized  patches,  no  inflammation  of 
Littre's  glands  or  of  the  crypts  of  Morgagni.  Prostate  nor- 
mal. It  is  a  typical  case  of  post-gonorrheal  aseptic  catarrh. 
I  order  general  tonic  measures,  hot  and  cold  sitz  baths  on 


CHRONIC  GONORRHEA  95 

alternate  days,  and  leaving  the  urethra  entirely  alone. 
After  two  weeks  the  condition  is  greatly  improved.  A  few 
injections  of  zinc  acetate  and  hydrastis  make  the  cure  com- 
plete. 

Case  4.  Had  the  first  attack  of  gonorrhea  three  years 
ago,  of  which  he  claims  to  have  been  entirely  cured.  Second 
attack  a  year  ago,  and  has  had  it  ever  since.  The  discharge 
is  slight  in  amount  but  is  always  there.  Even  half  an  hour 
after  urinating  the  discharge  will  appear  spontaneously  or 
can  be  readily  expressed.  In  the  two-glass  test,  shreds  in 
the  urine  very  numerous  in  both  glasses.  Has  been  using 
a  hand  injection  all  the  time,  with  numerous  internal  rem- 
edies. The  gonococci  in  the  discharge  are  in  great  multi^ 
tudes.  An  examination  with  a  bougie-a-boule  shows  the 
presence  of  three  organic  strictures,  irritable  and  painful. 
It  is  clearly  seen  that  the  injection  he  has  used  never  passed 
beyond  the  first  stricture  and  was  practically  useless,  as  far 
as  any  effect  on  the  entire  extent  of  the  mucous  membrane 
beyond  that  stricture  was  concerned.  Endoscopic  examina- 
tion shows  numerous  sclerosed  patches  and  a  very  severely 
inflamed  posterior  urethra.  After  irrigating  the  urethra  so 
that  the  fluid  passes  out  clear  and  without  any  shreds  and  ex- 
pressing the  prostate,  a  prostatitis  with  gonococci  in  the  pros- 
tatic discharge  is  plainly  demonstrated.  There  are  also  in- 
dications that  the  seminal  vesicles  are  affected.  This  case  of 
course  is  in  an  entirely  different  category  from  the  previous 
three  cases,  and  demands  dilatation  of  the  strictures,  irriga- 
tions of  the  entire  urethra,  instillations  in  the  posterior  ure- 
thra, endoscopic  applications  to  the  sclerosed  and  granular 
patches,  and  prolonged  prostatic  massage  before  a  cure  is 
effected. 


96       GONORRHEA  AND  ITS  CO]\IPLICATIONS 

Case  5.  Has  had  the  disease  for  two  years,  but  not  con- 
tinuously. Some  times  for  two  or  three  months  he  will 
have  no  sjonptoms  whatever.  The  urine  will  be  perfectly 
clear,  transparent,  and  free  from  shreds.  Then  all  at  once 
a  discharge  will  appear,  which  will  keep  up  for  a  month 
or  two  and  then,  with  or  without  treatment,  will  disappear. 
An  examination  shows  the  urethra  to  be  practically  nor- 
mal. The  urine  in  both  glasses  is  clear,  but  if  he  urinates 
in  a  third  glass  and  at  the  very  last  is  told  to  strain  hard, 
then  the  last  portion  will  contain  some  small  shreds  and  a 
little  secretion,  which  examination  shows  to  come  from  the 
prostate.  Expression  of  the  prostate  yields  large  masses 
of  muco-purulent  material.  In  short,  the  examination 
shows  that  the  man  really  has  no  urethritis,  only  a  prosta- 
titis, and  that  the  reinfections  and  irritations  of  the  urethra 
come  from  the  prostate  gland.  Treatment  directed  exclu- 
sively to  the  prostate  effects  a  cure  in  four  months. 

An  analysis  of  the  above  cases,  brief  and  cursory  though 
it  be,  shows  that  what  goes  under  the  name  of  chronic  gonor- 
rhea is  not  a  distinct  entity,  and  that  we  cannot  hope  to  treat 
all  cases  of  chronic  gonorrhea  by  one  set  formula.  Here, 
if  anywhere,  we  must  ''treat  the  patient  and  not  the  dis- 
ease. ' ' 

But  now,  having  emphasized  these  things,  having,  I  hope, 
succeeded  in  impressing  upon  the  mind  of  the  physician 
that  discrimination  and  judgment  is  necessary  in  the  treat- 
ment of  every  case  of  chronic  gonorrhea  (much  more  so 
than  in  the  acute  variety),  I  permit  myself  to  give  a  general 
outline  of  the  treatment  of  the  majority  of  cases  as  they 
present  themselves  to  the  general  practitioner. 


CHAPTER  XVII 
THE  TREATMENT  OF  CHRONIC  GONORRHEA 

Here,  as  in  acute  gonorrhea,  we  may  divide  the  treatment 
into  general,  internal  and  local. 

General.  The  general  treatment  in  chronic  gonorrhea  is 
of  minor  importance.  Things  that  may  prove  very  in- 
jurious in  acute  gonorrhea  are  permissible  in  the  chronic 
variety;  not  only  permissible  but  sometimes  distinctly  in- 
dicated. The  patient  may  lead  his  usual  mode  of  life,  and 
need  observe  but  little  restriction  even  as  far  as  alcohol  is 
concerned.  In  fact  patients  who  have  been  used  to  alco- 
holic beverages  often  do  better  when  permitted  to  partake 
of  small  amounts  of  wine  or  beer  than  when  entirely  cut 
off  from  any  alcoholic  indulgence.  Many  cases  who  have  an 
obstinate  catarrh  of  the  urethra  which  does  not  seem  to 
yield  to  any  measures  show  rapid  improvement  when  per- 
mitted to  drink  some  beer  or  wine  or  even  whiskey.  (See 
the  chapter:  Gonorrhea  vs.  Alcohol,  Tobacco  and  Sexual 
Intercourse.)  Exercise  is  also  permissible,  in  fact  many 
patients  begin  to  do  very  much  better  when  permitted  to 
exercise.  Of  course,  common  sense  is  here  necessary  as  in 
every  other  department  of  medicine.  For  instance,  if  the 
patient  has  as  a  part  of  his  chronic  gonorrhea  also  a  chronic 
prostatitis,  particularly  one  which  shows  ready  exacerba- 
tions, then  he  will  abstain  from  any  exercise  which  involves 
the  lower  part  of  the  body,  such  as  running,  bicycling,  auto- 

97 


98       GONORRHEA  AND  ITS  COMPLICATIONS 

mobiling,  etc.  This  is  also  true  of  cases  which  had  an  epi- 
didymitis. In  some  patients  an  epididymitis  is  apt  to  re- 
occur on  the  slightest  provocation,  and  such  patients  will 
do  better  to  abstain  from  any  exercise,  such  as  walking,  etc., 
until  practically  cured.  Sexual  intercouse  in  moderation 
is  also  permissible ;  nay,  in  many  cases  it  is  the  strictly  en- 
joined complete  abstinence  which  is  responsible  for  the 
keeping  up  of  the  prostatitis,  congestion  of  the  posterior 
urethra  and  discharge.  The  only  injunction  you  need  give 
to  the  patient  is  to  see  to  it  that  his  bowels  move  regularly 
and  that  he  does  not  permit  himself  to  get  constipated,  but 
this  is  a  good  injunction  for  anybody,  even  one  who  does 
not  suffer  with  gonorrhea.  Bathing,  both  hot  and  cold,  is 
decidedly  useful.  A  change  of  air  is  not  indicated.  When 
a  physician  sends  a  case  of  chronic  gonorrhea  to  the  country 
or  for  a  sea  voyage  it  is  because  he  has  exhausted  all  his 
resources,  he  wants  to  get  rid  of  the  patient  or  he  wants 
to  try  something  on  a  "perhaps."  I  have  not  found  it 
necessary  in  any  case. 

Internal  Treatment.  The  internal  treatment  is  also  of 
very  minor  importance  in  chronic  gonorrhea.  Indeed  in  a 
very  large  number  of  cases  of  chronic  gonorrhea  we  can  get 
along  without  a  single  drop  of  any  internal  medication 
whatever.  If  we  do  give  internal  treatment  it  is  not  with 
the  hope  of  attacking  the  gonorrheal  foci  but  for  secondary 
reasons.  For  instance,  if  there  is  a  mixed  infection  or  an 
accompanying  cystitis  we  may  give  urotropin  and  sodium 
benzoate.  When  we  use  sounds  or  dilators  in  the  urethra 
we  also  give  liberal  doses  of  urotropin  both  before  and  after 
treatment  to  prevent  infection.  In  giving  silver  nitrate  in- 
stillations the  reaction  is  sometimes  very  severe — that  is, 


TREATMENT  OF  CHRONIC  GONORRHEA   99 

the  stran^ry  and  burning  on  urination.  To  alleviate  these 
symptoms  we  give  sandalwood  or  gonosan,  etc.  Where  the 
patient  shows  a  tendency  to  recurrent  epididymitis,  then 
good  doses  of  sodium  salicylate,  salol  or  aspirin  may  be  in- 
dicated. Sometimes  when  the  patient  is  foolish  and  in- 
clined to  be  neurasthenic  we  must  give  him  a  placebo.  The 
placebo  will  have  no  direct  effect  on  the  genito-urinary 
tract,  but  it  is  good  for  his  nerves.  To  repeat,  I  do  not 
exclude  internal  medication  entirely  in  the  treatment  of 
chronic  gonorrhea,  but  I  do  not  give  it  with  any  hopes  of 
direct  effect  on  the  genito-urinary  lesions. 

Local  Treatment.  This  is  the  most  important  and  is  in. 
the  vast  majority  of  cases  the  only  treatment  indicated. 
Briefly  stated,  the  treatment  consists  of  injections,  and  irri- 
gations, instillations,  dilatation  and  endoscopic  applica- 
tions. 

The  drug  par  excellence  in  chronic  urethritis  is  silver 
nitrate,  and  with  this  drug  alone,  properly  used,  we  can 
cure  a  very  large  percentage  of  our  cases.  It  is  used  either 
in  the  form  of  irrigation,  injection,  instillation  or  concen- 
trated application.  For  irrigation  purposes  I  use  it  in  the 
strength  of  1  in  10,000,  increasing  the  strength  to  1  in 
1,000.  By  increasing  the  strength  very  gradually  we  avoid 
irritation,  with  the  consequent  discharge,  strangury,  and  so 
forth.  The  amount  used  per  irrigation  differs  from  8  to  32 
ounces  (250  to  1,000  c.c).  This  irrigation  is  repeated  twice 
a  week  as  a  rule.  In  many  cases  once  a  week  suffices.  The 
entire  urethra  is  irrigated,  for  while  in  the  acute  disease 
we  distinguish  between  anterior  and  posterior  urethritis, 
there  is  practically  no  line  of  demarcation  in  the  chronic 
variety — the  entire  canal  is  more  or  less  affected.    If  the 


100       GONORRHEA  AND  ITS  COIMPLICATIONS 

neck  of  the  bladder  also  shows  signs  of  implication  in  the 
gonorrheal  process  the  bladder  is  also  irrigated,  but  here  it 
is  best  to  use  a  few  drops  of  a  strong  solution,  1  per  cent., 
by  instillation. 

Irrigation  may  be  performed  by  the  means  of  the  well 
known  Janet- Valentine  irrigator,  but  I  prefer  to  use  a 
large  Janet-Frank  syringe  of  150  to  250  c.c.  capacity. 

For  injection  purposes  I  use  the  silver  nitrate  in  the 
strength  of  1-1,000  to  1-250,  and  generally  from  2  to  6 
drams  at  a  time.  While  the  irrigating  fluid  is  permitted  to 
run  right  out  the  injection  fluid  is  made  to  remain  in  the 
urethra  from  2  to  5  minutes. 


Guyon  Syringe  and  Catheter. 


Instillations  I  use  generally  when  the  posterior  urethra 
and  the  neck  of  the  bladder  is  affected.  For  this  purpose 
I  use  almost  exclusively  the  soft  rubber  Guyon  catheter  and 
syringe.  The  strength  of  the  solution  varies  from  1  to  5 
per  cent,  and  from  3  to  20  drops  are  deposited  on  the 
affected  portion. 

When  endoscopic  examination  shows  the  presence  of  local- 


TEEATMENT  OF  CHRONIC  GONORRHEA   101 

ized  patches  of  inflammation  or  erosion  then  topical  applica- 
tions through  the  endoscope,  applications  to  the  spot,  are 
indicated.  The  applications  are  made  by  the  aid  of  a  cotton 
carrier,  and  the  strength  of  the  silver  nitrate  solution  may 
be  from  1  to  10  per  cent.  Instead  of  silver  nitrate,  a  mix- 
ture of  equal  parts  of  tincture  of  iodine  and  phenol  is  often 
markedly  beneficial. 


Guyon  Syringe,  French  make 


Ultzman  Syringe 

I  stated  that  by  silver  nitrate  alone  we  can  cure  a  large 
majority  of  cases.  But  not  all.  In  some  cases  silver  ni- 
trate exerts  a  decidedly  injurious  effect.  The  patient's 
mucous  membrane  seems  to  possess  an  idiosyncrasy  against 
silver  nitrate.  The  condition  of  the  urethra  remains  either 
entirely  unaffected  by  the  silver  nitrate  or  becomes  worse. 
In  such  cases  we  must  have  recourse  to  other  chemicals, 
and  zinc  sulphate  is  one  of  the  best.  How  do  we  know 
whether  to  use  silver  nitrate  or  zinc  sulphate  ?  We  do  not. 
The  treatment  of  chronic  urethritis  is  unfortunately  still 
in  the   empirical   stage.     We   can  never   predict   before- 


102     GONORRHEA  AND  ITS  COMPLICATIONS 

hand  just  how  a  certain  chemical  will  affect  a  patient's 
urethra  and  how  long  the  treatment  will  last.  We  must 
simply  keep  on  trying.  We  use  first  one  drug  and  if  the 
patient's  urethra  responds  well  to  the  treatment  we  con- 
tinue to  use  it,  perhaps  changing  the  strength  now  and  then, 
but  if  after  a  few  applications  (i.e.,  irrigations,  injections  or 
instillations)  the  condition  remains  the  same  or  becomes 
worse,  then  we  have  to  change  to  another  drug.  It  is  per- 
fectly ridiculous  to  keep  on  with  silver  nitrate  for  months 
and  months  at  a  time,  as  some  physicians  do  even  when  they, 
do  not  notice  the  slightest  improvement.  Because  silver 
nitrate  is  a  very  beneficial  drug  in  some  cases  of  chronic 
urethritis,  it  does  not  mean  that  it  is  beneficial  in  all  cases. 
The  beneficial  effect  must  show  itself  soon,  and  if  it  fails 
to  show  itself  a  change  is  indicated. 

The  zinc  sulphate  may  be  used  in  strengths  of  3^  of  1  per 
cent.,  to  5  per  cent.,  that  is  from  1  gr.  to  the  ounce  of  water  to 
25  grs.  to  the  ounce  of  water.  Often  it  is  well  to  alternate 
the  zinc  sulphate  with  some  other  astringent,  such  as  copper 
sulphate,  1  to  2  grs.  to  the  ounce.  Latterly  iodine  has  given 
me  good  results  in  a  restricted  number  of  cases.  It  is 
generally  in  those  cases  in  which  silver  nitrate  proves  irri- 
tating that  tincture  of  iodine  in  a  very  diluted  form  (5  to 
25  drops  of  the  official  tincture  to  an  ounce  of  water)  proves 
beneficial.  For  applications  through  the  endoscope  the 
pure  tincture  may  be  used. 

If  the  patient  cannot  come  to  the  doctor 's  office  frequently 
enough  then  we  must  sometimes  prescribe  an  injection  for 
him  to  use  on  himself.  In  such  cases  the  best  injections  are 
a  2  per  cent,  solution  of  ichthyol  or  a  2  per  cent,  solution 
of  zinc  sulphate  or  zinc  acetate,  or  the  zinc  sulphate,  lead 


TEEATMENT  OF  CHRONIC  GONORRHEA   103 

acetate  and  bismuth  sub-nitrate  mixture  (see  Formulary). 
Alternating  injections  will  always  give  better  results  than 
using  the  same  injection  uninterruptedly.  I  therefore 
often  have  my  patient  use  two  injections  on  the  same  day 
or  different  injections  on  alternate  days. 

Irrigations,  injections  and  instillations  will  cure  the  great 
majority  of  cases,  but  where  there  are  strictures,  either  fully 
formed  or  in  the  process  of  formation,  or  sclerosed  patches, 
all  these  measures  will  often  prove  inefficient.  Here  we 
have  another  procedure  which  is  generally  very  helpful. 


Dilator  for  Anterior  Urethra 


Dilator  for  Posterior  Urethra 


This  is  dilatation  by  the  means  of  sounds  or  dilators.  What 
the  exact  rationale  is  of  the  benefit  by  sounds  and  dilators 
is  not  very  clear,  but  there  is  no  question  that  dilatation, 
if  not  abused,  has  a  remarkably  beneficial  effect  on  the 
course  of  chronic  urethritis.  The  use  of  the  sounds  is 
simpler  than  that  of  dilators,  but  the  superiority  of  the 
dilator  over  the  sound  lies  in  the  fact  that  the  former  can 
be  passed  through  a  small  meatus  and  then  dilated  in  the 
urethra  to  any  desired  circumference,  while  in  treatment 
with  sounds  we  must  perform  meatotomy  if  the  patient 


104       GONORRHEA  AND  ITS  COj\iPLICATIONS 

happens  to  have  a  narrow  meatus,  wMcli  is  quite  frequently 
the  case.  The  proper  interval  for  the  use  of  sounds  and 
dilators  is  once  every  five  days.  Once  a  week  is  often  suffi- 
cient, but  they  should  never  be  used  more  than  twice  a  week. 
I  do  not  believe,  however,  that  much  benefit  can  be  derived 
from  leaving  the  sound  or  dilator  in  one  or  two  minutes. 
Ten  minutes  is  about  the  proper  period.  It  may  be  left  in 
as  long  as  twenty  minutes. 

"Where  there  are  indurated  patches  and  inflamed  glands 
and  lacunae,  it  is  well  to  massage  them  over  the  sound 
(while  the  sound  is  in  the  urethra),  and  we  often  succeed 
in  expressing  a  good  deal  of  secretion  from  them.  Properly 
performed  such  a  massage  over  sound  or  dilator  with  pains- 
taking expression  contributes  a  good  deal  towards  the  cure 
of  the  most  obstinate  gonorrheas. 

A  small  percentage  of  patients  are  very  sensitive  to  the 
use  of  dilators  or  sounds  and  are  apt  to  get  what  we  call  a 
urethral  chill  and  an  aggravation  of  all  other  symptoms,  but 
this  usually  occurs  only  after  the  first  or  first  and  second 
treatments.  If  done  gently  and  aseptically,  all  trouble  can 
be  avoided.  Always  remember,  however,  to  have  the  pa- 
tient take  a  good  dose  of  hexamethylenamine  before  he  comes 
to  your  office  and  give  him  one  when  he  is  leaving  the 
office. 

There  are  on  the  market  also  irrigating  dilators,  where 
the  irrigation  and  dilatation  can  be  performed  simul- 
taneously, but  I  believe  that  these  instruments  are  best  left 
in  the  hands  of  the  specialist. 

The  proper  method  of  procedure  in  treating  a  patient  by 
sounds  or  dilators  is  as  follows :  ( 1 )  the  patient  urinates ; 
(2)  the  urethra  is  washed  out  with  a  warm  boric  acid  solu- 


TEEATMENT  OF  CHRONIC  GONOREHEA   105 

tion,  2  per  cent.,  or  a  1-10,000  mercury  oxycyanide  solu- 
tion; (3)  the  sound  or  dilator,  properly  asepticized  and 
lubricated  (with  a  water  soluble  and  not  an  oily  lubricant) 
is  passed  into  the  urethra  and  allowed  to  remain  ten,  fif- 
teen or  twenty  minutes;  (4)  the  urethra  is  again  washed 


Irrigating  Dilator   for   the  Anterior   Urethra 


Irrigating  Dilator  for  the  Posterior  Urethra 

out  with  a  warm  boric  acid  or  a  normal  salt  solution; 
(5)  the  injection,  irrigation  or  instillation  proper,  with 
silver  nitrate,  zinc  sulphate,  diluted  tincture  of  iodine,  or 
whatever  else  may  be  decided  upon,  is  administered. 

Such  a  treatment  as  outlined  above  gives  results,  definite 
and  positive  results.  And  I  personally  believe  that,  prop- 
erly speaking,  there  is  no  such  thing  as  an  incurable  case 
of  gonorrhea.  Every  case  is  curable,  for  all  practical  pur- 
poses. There  are  hundreds  of  thousands  of  cases  of  un- 
cured,  and  under  our  present  conditions  incurable  cases, 
but  the  fault  is  not  with  our  lack  of  knowledge.  It  resides 
in  the  social  and  economic  conditions  of  the  patient,  which 
prevent  him  from  employing  a  competent  physician  for  the 
proper  length  of  time. 


106     GONOERHEA  AND  ITS  COMPLICATIONS 

VACCINOTHERAPY 

The  reader  may  be  surprised  that  in  outlining  the  treat- 
ment of  acute  and  chronic  gonorrhea  I  have  not  made  any 
mention  of  the  vaccines  or  bacterins.  The  reason  is  a  very 
simple  one.  I  have  not  done  so  because  I  am  not  an  en- 
thusiastic believer  in  them.  Now,  do  not  drav  false  con- 
clusions. It  does  not  mean  that  I  do  not  believe  in  t  ic 
vaccine  treatment  of  any  disease,  nor  does  it  mean  that  I 
do  not  believe  in  the  value  of  vaccine  treatment  of  certain 
complications  of  gonorrhea,  particularly  of  arthritis.  It 
does  not  even  mean  that  I  deny  that  the  administration  of 
vaccines  may  prove  of  value  in  some  cases  of  chronic  gonor- 
rhea. It  does  mean,  however,  that  I  believe  the  percentage 
of  cases  in  which  the  gonococcic  vaccines  or  bacterins,  either 
the  simple  or  the  mixed,  is  of  benefit,  is  so  slight  that  it  is 
not  worth  while  advising  their  use  to  the  general  practi- 
tioner. 

I  believe  that  on  the  whole  more  harm  than  good  is  being 
done  by  them.  I  have  patients  sent  to  me  from  different 
parts  of  the  country  on  whom  vaccinotherapy  has  been  prac- 
ticed for  weeks,  months  and  even  years,  and  not  only  with- 
out any  benefit  but  with  distinct  injury,  and  for  this  reason 
I  do  not  care  to  enlarge  upon  the  subject  in  this  book.  Still, 
if  a  physician  wishes  to  use  the  vaccines  or  bacterins  in  any 
of  his  obstinate  cases  he  is  welcome  to  do  so.  He  needs  no 
instructions  from  us  on  this  subject,  for  the  packages  come 
ready  prepared  and  he  can  readily  obtain  all  the  necessary 
literature  from  the  manufacturers. 

I  wish,  however,  to  repeat  that  both  from  my  personal 
experience  and  from  an  analytical  study  of  the  reports  of 


TREATMENT  OF  CHRONIC  GONORRHEA  107 

conscientious  investigators  (not  those  who  rush  into  print 
with  their  successes  with  every  new  remedy),  I  am  con- 
vinced that  the  antigonococcic  serums,  vaccines  and  bac- 
terins,  not  even  excepting  the  latest  of  Nicolle  and  Blaizot, 
are  of  but  slight  if  any  value  in  the  treatment  of  gonorrheal 
urethritis.  That  an  efficient  vaccine  may  be  produced  in 
the  future  is  possible,  but  this  is  not  yet  the  case.  We  have 
not  yet  an  efficient  anti-gonococcic  vaccine,  and  of  those  we 
do  have  we  are  still  in  ignorance  as  to  dosage,  intervals  of 
administrations,  indications  and  contraindications.  To 
shoot  a  patient  full  of  bacteria  on  the  principle  that  they 
may  do  some  good  is  neither  scientific  nor  fair.  I  at  least 
cannot  give  it  my  approval. 

And  in  this  connection  the  ^  following  quotation  from 
Adami  is  pertinent.  This  careful  and  thoughtful  physician 
says: 

"Thus  as  a  final  principle  it  may  be  laid  down — and  I 
do  this  with  a  full  sense  of  the  necessity  and  responsibility 
that  attaches  thereto — that  vaccine  therapy  is  not  to  be 
undertaken  by  the  ordinary  practitioner;  there  are  too 
many  dangers  attaching  thereto ;  and  with  this  corollary, 
that,  excellent  as  may  be  the  stock  vaccines  prepared  by 
certain  firms,  to  advertise  these  light-hear|edly  and  recom- 
mend them  and  their  employment  far  and  wide  deserves 
the  condemnation  of  this  association  and  all  interested  in 
the  wellbeing  of  their  fellow-men."  (Symposium  on  Vac- 
cine Therapy,  Meeting  of  the  Association  of  American 
Physicians,  1910,  quoted  from  American  Journal  of 
Urology,  Jan.,  1911,  p.  25.) 

And  the  following  quotation  from  Yaughan  emphasizes 
still  more  strongly  the  necessity  for  caution  and  the  great 


108       GONORRHEA  AND  ITS  COMPLICATIONS 

danger  that  may  arise  from  the  use  of  vaccines  by  the  gen- 
eral practitioner : 

' '  Every  time  an  unbroken  protein  is  introduced  into  the 
body  it  carries  with  it,  and  as  a  part  of  it,  a  poison.  From 
the  very  careless,  rash  and  unwarranted  way  in  which  '  vac- 
cines'  of  most  diverse  origin  and  composition  are  now  used 
in  the  treatment  of  disease,  this  matter  certainly  cannot  be 
understood  or  its  danger  appreciated  by  those  who  subject 
their  patients  to  such  risks.  It  should  be  clearly  under- 
stood that  all  proteins  contain  a  poisonous  group — a  sub- 
stance which  in  a  dose  of  0.5  mg.  injected  intravenously 
kills  a  guinea-pig.  Not  only  do  these  proteins  contain  a 
poison,  but  when  introduced  parenterally  the  poison  is  set 
free,  not  in  the  stomach,  from  which  it  may  be  removed,  but 
in  the  blood  and  tissues.  It  is  possible  that  vaccine  therapy 
may  become  of  great  service  in  the  treatment  of  disease. 
Even  now  there  are  occasional  brilliant  results  which  are 
reported,  while  the  failures  and  disasters  are  not  so  widely 
advertised."  (From  Vaughan's  book,  ^'Protein  Split 
Products  in  Relation  to  Immunity  and  Disease.") 


CHAPTER  XVIII 

THE  LENGTH  OF  TIME  REQUIRED  TO  CURE 
CHRONIC  GONORRHEAL  CONDITIONS 

''How  long  will  it  take  me  to  get  cured?"  is  a  question 
very  frequently  addressed  to  us  by  our  patients  afflicted 
with  chronic  gonorrhea  or  its  complications.  To  some  it  is 
just  a  matter  of  interest,  to  some  it  is  a  matter  of  vital  im- 
portance, either  because  they  want  to  or  must  get  married 
at  a  certain  time,  or  because  their  financial  resources  are 
limited  and  they  can  spend  only  so  much.  But  invariably 
my  answer  is:  "I  don't  know;  it  will  take  as  long  as  it 
will  take."  And  I  explain  to  them  briefly  but  understand- 
ably, the  character  of  their  disorder,  the  difference  between 
an  acute  and  chronic  gonorrhea,  the  anatomic  structure  of 
the  genital  organs  and  glands,  and  why  it  is  impossible  to 
state  beforehand,  even  approximately,  how  long  it  will  take 
to  cure  a  certain  case.  For  instance,  a  case  of  chronic 
prostatitis  or  seminal  vesiculitis.  We  will  say  it  takes  on 
the  average  four  to  six  months;  it  may  take  only  two 
months;  but  it  may  take  a  year  or  more.  If  the  patient  is 
willing  to  subject  himself  to  treatment,  under  these  condi- 
tions, well  and  good ;  if  not,  also  well  and  good.  The  intel- 
ligent and  financially  able  patient  is  sure  to  agree.  Under 
no  circumstances  is  a  patient  taken  under  false  pretenses, 
or  under  a  misunderstanding.  And  it  is  only  with  such 
complete  previous  understanding  that  the  treatment  of  a 
chronic  gonorrheal  patient  can  be  carried  on  successfully, 

109 


110     GONOERHEA  AND  ITS  COMPLICATIONS 

and  the  patient  never  has  any  pretensions.  Some  physi- 
cians, for  fear  of  losing  the  patient,  do  not  make  it  clear  to 
him  as  to  the  probable  length  of  time,  or  even  deliberately 
mention  a  short  period :  a  month  or  two.  More  is  the  pity. 
They  hurt  themselves  eventually  more  than  if  they  told  the 
truth  frankly  at  the  outset.  And  they  also  hurt  the  medical 
profession  in  general,  by  destroying  the  confidence  of  the 
public  in  the  reliability  of  the  doctor's  statements.  Of 
course  not  every  physician  is  sufficiently  secure  financially 
to  be  able  to  deal  with  patients  with  perfect  independence 
and  not  to  mind  if  he  does  lose  a  patient.  Again,  more  is 
the  pity.  Because  it  is  only  the  perfectly  independent 
physician  who  can  do  his  patients  the  most  good. 

And  the  following  case  will  demonstrate  what  can  be 
accomplished  in  apparently  hopeless  cases  by  persistent  un- 
remitting treatment.  Mr.  A.,  age  28,  got  an  attack  of  gonor- 
rhea at  the  age  of  24,  and  he  has  had  the  gonorrhea  and 
some  of  its  complications  ever  since.  He  was  treated  by 
several  general  practitioners.  I  examined  him  and  found: 
two  strictures,  barely  passable  by  15  F ;  a  beautiful  prosta- 
titis, with  prostate  enlarged  and  sensitive,  with  purulent 
secretion  easily  expressible ;  a  bilateral  spermatocystitis ; 
granular  and  sclerosed  patches  in  the  urethra.  A  slight 
gleety  discharge  constantly  present:  not  only  in  the  morn- 
ing, but  also  throughout  the  day.  Urine  turbid,  full  of 
shreds  and  bacteria,  and  some  pus.  The  patient  knew  that 
his  condition  was  a  severe  one,  and  he  did  not  ask  how 
long  it  would  take  him  to  get  cured.  In  fact  he  said  he 
did  not  care  how  long  it  took.  He  was  disgusted  with  his 
condition  and  he  was  determined  to  get  cured,  if  there  was 
any  possibility  of  his  getting  cured.     He  came  faithfully 


TIME  REQUIRED  TO  CURE  111 

twice  a  week  for  over  a  year ;  the  prostatitis  improved  after 
six  months,  but  the  spermatocystitis  was  rebellious  and 
showed  no  improvement.  Nor  was  it  possible  to  improve 
the  condition  of  the  urine.  I  told  him  that  there  was  but 
little  hope  for  further  improvement,  unless  the  treatment 
w^as  continued  for  a  very  long  time.  He  said  he  did  not 
care  if  it  took  five  years.  He  came  regnlarly  once  or  twice 
a  week  for  another  year.  He  became  a  joke,  a  regular  fix- 
ture in  the  office.  No  weather  could  keep  him  back.  Every 
Sunday  and  Wednesday  he  was  there.  I  got  tired  of  him. 
I  should  have  been  glad  if  he  had  also  gotten  tired.  But 
he  did  not  get  tired,  nor  discouraged.  Had  he  been  a  sexual 
neurasthenic,  with  imaginary  troubles,  with  no  anatomic 
basis  for  his  sufferings,  I  would  have  gotten  rid  of  him 
long  before.  But  he  was  not  a  bit  neurasthenic,  and  there 
was  a  real  pathologic  basis  for  his  condition.  And  so  I 
consented  to  continue  to  treat  him.  At  the  end  of  three" 
years  and  two  months  I  discharged  him  as  absolutely  cured. 
His  urine  was  clear  and  sparkling,  the  granular  patches  and 
strictures  were  no  more,  and  the  prostate  and  seminal 
vesicles  were  normal.  Not  only  were  their  secretions  free 
from  gonococci,  they  were  free  from  any  other  bacteria  as 
well.  Here  was  a  case  of  patience  well  rewarded.  Four 
years'  irregular  treatment  which  aggravated  his  condition 
before  he  came  to  me,  and  three  years  under  my  care — 
seven  years  altogether.  And  why  was  he  so  methodical,  so 
persistent,  so  regular  in  his  treatment  during  the  past  three 
years?  First,  because  he  had  absolute  unquestioning  con- 
fidence ;  second,  because  he  wanted  to  get  well ;  and  third, 
most  important,  there  was  a  little  girl  whom  he  was  going 
to  make  his  wife. 


112      GONORRHEA  AND  ITS  COMPLICATIONS 

And  so,  while  I  believe  that  every  case  of  gonorrhea  and 
its  complications  is  curable,  we  must  refuse  to  give  a  time 
limit.  And  we  must  also  bear  in  mind  another  thing.  A 
urethra  that  has  been  the  subject  of  gonorrhea  of  many 
years'  standing  presents  forever  after  a  locus  resist entiae 
minoris,  and  may  under  certain  predisposing  causes  de- 
velop a  mild  urethritis,  a  slight  catarrh.  You  discharge  a 
patient  cured.  Urethra  normal  in  every  sense  of  the  word, 
urine  clear  and  sparkling,  no  complications  of  any  kind.  In 
six  months  the  patient  comes  to  you,  with  a  slight  discharge, 
or  perhaps  only  a  little  burning  sensation  on  urination  or 
during  intercourse.  You  examine  him.  No  gonococci,  no 
bacteria  of  any  kind,  or  perhaps  a  staphylococcus  here  and 
there.  You  give  him  one  or  two  instillations  of  AgNOg, 
and  he  is  well  again  for  a  year  or  two.  Then  he  comes 
again  with  the  same  slight  trouble,  and  again  you  fix  him 
up  in  one  or  two  visits.  I  have  several  patients  who  come 
regularly  once  or  twice  a  year  for  the  purpose  of  passing  a 
sound  or  receiving  a  silver  nitrate  instillation.  They  come 
at  the  first  appearance  of  a  disagreeable  symptom  in  the 
urethral  canal  or  in  the  prostate :  a  little  itching  or  burning, 
or  a  little  heavy  sensation.  And  then  they  are  all  right 
again,  and  are  thus  kept  in  good  condition  all  the  time. 
I  don't  see  anything  terrible  or  objectionable  in  a  patient, 
who  had  suffered  with  gonorrhea  for  several  years,  being 
obliged  to  make  a  few  visits  to  a  specialist  once  or  twice  a 
year,  so  as  to  prevent  the  development  of  any  trouble  in 
his  weakened  urethra.  People  go  to  the  dentist  regularly 
once  or  twice  a  year.  Why  should  not  people  who  went 
through  a  severe  attack  of  gonorrhea  visit  the  genito-urinary 


TIME  REQUIRED  TO  CURE  113 

specialist  once  or  twice  a  year,  to  prevent  any  possible 
trouble,  or  to  cut  short  any  trouble  in  its  incipiency  ? 

To  summarize:  I  believe  in  the  curability  of  every  case 
of  chronic  gonorrhea  and  its  complications.  But  as  to  the 
time  required,  there  is  no  telling  definitely.  If  pressed  for 
an  answer  I  would  say:  A  small  percentage  get  cured  in 
a  month  or  two,  a  larger  percentage  in  four  to  six  months, 
a  somewhat  smaller  percentage  in  eight  to  twelve  months, 
and  a  very  small  percentage  requires  longer  than  a  year — 
a  year  and  a  half,  two  years,  or  exceptionally,  if  there  are 
many  complications,  even  three  years. 

In  conclusion  I  will  reproduce  a  little  editorial  note  from 
the  Critic  and  Guide  (November,  1914)  entitled:  Curable 
and  Incurable.  It  is  a  propos  the  subject  under  discus- 
sion and  is  as  follows : 

CURABLE   AND   INCURABLE 

There  is  not  a  single  incurable  case  of  gonorrhea. 

There  are  in  the  United  States  a  million  incurable  ca^es 
of  gonorrhea. 

Very  contradictory,  at  first  sight. 

Not  a  bit  contradictory. 

What  I  mean  by  the  two  statements  is  this :  there  is  not  in 
my  opinion  a  single  case  of  gonorrhea  which  if  properly  and 
skillfully  treated  and  treated  long  enough  could  not  be  cured 
eventually.  But  there  are  about  a  million  gonorrheal  pa- 
tients to  whom  prolonged,  proper  and  skillful  treatment  is 
an  absolute  impossibility,  an  unrealizable  dream.  They 
simply  must  go  on  with  their  lesion  or  lesions  to  the  end  of 
their  days.    Naturally,  such  are  incurable  cases.     There 


114     GONORRHEA  AND  ITS  COMPLICATIONS 

are  a  few  chronic  aggravated  conditions  to  cure  which  might 
take  a  year  or  two  at  a  cost  of  a  hundred,  five  hundred  or 
perhaps  even  a  thousand  dollars.  Can  the  poor  man  or  the 
average  person  afford  it?  But  that  does  not  mean  that 
scientifically  speaking  such  cases  .are  not  curable.  But 
economic  conditions  are  often  at  loggerheads  with  scientific 
medicine,  and  poverty  often  renders  a  disease,  which  is 
theoretically  curable,  practically  incurable. 

So,  there  is  nothing  contradictory  in  the  above  two  state- 
ments. 


CHAPTER  XIX 

THE  INSTRUMENTS  USED  IN  THE  TREAT- 
MENT OF  GONORRHEA 

The  instniinents  required  for  the  proper  treatment  of 
gonorrhea  are  few  in  number.  The  general  practitioner  re- 
quires but  very  few  indeed ;  and  even  the  specialist  whose 
reputation  is  so  well  established  that  he  is  no  longer  in 
need  of  any  tricks  to  "impress"  the  patient,  can  get  along 
with  a  surprisingly  small  number. 

For  instance,  I  find  that  a  100  c.c.  syringe,  a  Guyon  in- 
stillator,  a  set  of  sounds,  a  Kollmann  dilator,  and  occasion- 
ally the  urethroscope,  are  all  the  instruments  I  need  in  90 
per  cent,  of  all  cases,  the  first  two  being  sufficient  in  at  least 
75  per  cent,  of  all  cases  of  acute  and  chronic  gonorrhea. 
Specialists  when  writing  for  the  general  practitioner  seem 
to  be  unable  to  resist  the  temptation  to  show  off  their  great 
erudition,  their  remarkable  skill  and  their  armamentarium 
chirurgicum.  I  will  present  only  what  is  actually  needed, 
what  is  in  daily  use. 

THE  patient's   SYRINGE 

The  first  instrument  we  have  to  discuss  does  not  really 
belong  to  the  doctor's  armamentarium,  but  is  the  patient's 
chief  and  only  instrument.  It  would  be  better  if  the  pa- 
tient did  not  have  to  use  any  injections  on  himself,  hav- 
ing them  all  given  by  the  doctor  or  an  intelligent  nurse ;  but 
as  this  cannot  be,  and  as  for  many  years  to  come  the  home 

115 


116      GONORRHEA  AND  ITS  CO^IPLICATIONS 

injection  treatment  will  remain  an  important  part  of  the 
treatment  of  gonorrhea,  it  is  important  to  see  that  the 
patient  gets  the  proper  syringe.  In  fact  the  success  of  the 
injections  often  depends  on  the  character  of  the  syringe : 
its  quality,  size,  action  of  the  piston  and  ease,  difficulty  or 
impossibility  of  asepticization. 

To  tell  a  patient,  as  doctors  very  often  do :     ^'  Here  is  a 
prescription  for  an  injection,  get  a  syringe  and  use  it  three 


Syringe  for  patients'  use 


Soft  Rubber  Tips  for  Urethral  Syringe 

times  a  day,"  is  simply  foolish,  not  to  use  a  stronger  word. 
The  doctor  must  show  the  patient  what  kind  of  a  syringe 
to  buy,  and  must  instruct  him  exactly  how  to  use  it.  He 
must  himself  give  him  at  least  one  injection,  and  then  make 
the  patient  inject  himself,  so  as  to  see  whether  or  not  he 
performs  this  little  but  important  operation  properly. 

The  best  syringe  for  the  patient  is  one  with  a  glass  bar- 
rel, hard  rubber  mounting  and  soft  rubber  tip.  It  should 
hold  three  to  four  drams.     If  the  patient's  anterior  ure- 


INSTRUMENTS  USED  IN  TREATMENT       117 

thra  is  very  small,  he  can  fill  the  syringe  only  two-thirds 
full,  or  he  injects  one  dram  first  and  lets  it  run  out,  which 
acts  as  an  additional  safeguard  against  pushing  germs  from 
the  anterior  into  the  posterior  urethra.  It  is  necessary  to 
see  that  the  piston  works  smoothly  and  not  in  jerks,  and 
that  the  syringe  does  not  leak. 

I  do  not  like  the  syringes  with  asbestos  packing,  for  they 
often  ''stick."  There  is  an  all  glass  syringe  on  the  mar- 
ket (aseptic),  which  theoretically  is  ideal,  but  it  has  the 
objection  that  the  piston  often  refuses  to  work  smoothly, 
and  the  barrel  is  apt  to  crack. 


Penis    Clamp,   put   over   the   glans   to   retain 
injections  for  10  or  15  minutes 

The  patient  may  take  the  injection  standing,  sitting  on 
the  edge  of  a  chair,  or  lying  down.  The  steps  are  as  fol- 
lows: The  patient  fills  the  properly  kept  and  rinsed  syr- 
inge. He  then  urinates,  wipes  off  the  glans  and  particu- 
larly the  meatus  with  a  piece  of  cotton  dipped  in  a  bichloride 
solution ;  then  he  raises  the  penis,  with  his  left  hand,  to  an 
almost  vertical  position,  opening  the  meatus  with  his  thumb 
and  forefinger,  then  takes  the  filled  syringe,  inserts  the  tip 
into  the  gaping  meatus  snugly,  pressing  it  gently  against 
the  lips,  so  that  the  injected  fluid  may  not  run  out ;  he  then 
presses  the  piston  down  gently  but  firmly  and  steadily,  until 
he  has  injected  about  a  dram  (%  of  the  contents  of  the  syr- 
inge) ;  he  removes  the  syringe  and  lets  this  quantity  run 


118     GONORRHEA  AND  ITS  COMPLICATIONS 

out.  He  reinserts  the  syringe  and  injects  the  remainder; 
holding  the  thumb  and  the  forefinger  on  each  side  of  the 
meatus,  he  removes  the  syringe,  and  quickly  compresses  the 
lips,  holding  in  the  solution  for  five  to  seven  minutes,  when 
he  voids  it.  He  then  rinses  the  syringe  with  plain  water, 
and  puts  it  in  the  bichloride  solution  ready  for  the  next  in- 
jection. Instead  of  compressing  the  meatus  with  the  fiiigers, 
a  penis  clamp  may  be  used. 

THE  physician's   SYRINGE 

A  syringe  of  100  to  150  c.c.  capacity  (3^  to  5  ounces) 
serves  a  number  of  useful  purposes.     It  can  be  used  for 


100  c.c.  Syringe  for  doctors'  use 

repeated  injection  of  the  anterior  urethra,  for  washing  out 
the  anterior  and  posterior  urethra,  and  for  filling  or  ir- 
rigating the  bladder.  The  best  syringe  for  these  purposes 
is  the  well  known  Janet-Frank  syringe.  It  has  a  glass  bar- 
rel, metal  mountings,  a  hard  composition  packing,  and  a 
screw  by  which  the  working  of  the  piston  can  be  regulated. 
The  sj^ringe  may  be  thoroughly  sterilized  by  boiling.  A 
soft  rubber  tip  is  used  with  the  syringe. 

The  Record  syringes  are  also  made  now  in  large  size— 
100-250  c.c. — but  I  do  not  find  them  so  convenient. 


CHAPTER  XX 

THE  ABORTIVE  TREATMENT  OF 
GONORRHEA 

We  come  here  to  one  of  the  most  important  questions  con- 
fronting the  genito-urinary  specialist:  Can  gonorrhea  he 
aborted?  Is  an  attempt  to  abort  gonorrhea  justifiable?  If 
the  first  question  can  be  answered  in  the  affirmative,  it  nat- 
urally follows  that  an  affirmative  answer  must  also  be  given 
to  the  second  question.  Gonorrhea  is  such  a  grave  disease, 
its  possible  complications  and  sequelae  are  so  serious  and  far- 
reaching,  that  a  really  effective  abortive  treatment  would  be 
a  boon  and  a  blessing  and  its  discoverer  would  rank  among 
humanity's  benefactors.  Unfortunately  we  are  not  yet  in 
possession  of  a  reliable  and  satisfactory  abortive  treatment, 
and  it  is  a  question  if  we  ever  will  be.  Not  that  we  do  not 
possess  efficient  bactericides  which  when  brought  in  contact 
with  the  gonococcus  will  surely  destroy  it.  But  when  the 
patients  come  to  us  the  gonococci  are  no  longer  on  the  sur- 
face, on  the  free  urethral  mucous  membrane,  but  have  dug 
beneath  the  surface  and  are  protected  by  several  layers  of 
epithelia  from  the  action  of  the  germicidal  solution.  We 
may  in  the  future  get  a  preparation  which  will  penetrate 
deeply  into  the  tissues,  but  so  far  such  a  preparation  is  not 
yet  at  our  command.  Another  objection  to  the  abortive 
treatment  is  that  it  is  apt,  in  a  large  number  of  cases,  to 
lead  to  serious  complications,  and  to  leave  the  patient  in  a 

119 


120       GONORRHEA  AND  ITS  CO:\IPLICATIONS 

much  worse  condition  than  when  he  applied  for  treatment. 
Casper  says  that  he  has  seen  cases  of  lymphangitis,  lympha- 
denitis, prostatitis  and  cystitis  develop  under  the  abortive 
treatment,  and  in  such  a  way  that  there  could  be  no  doubt 
as  to  the  causal  relationship  between  the  treatment  and  the 
complications.  ATe  know  personally  of  cases  where  an  at- 
tempt at  aborting  gonorrhea  with  silver  nitrate  was  fol- 
lowed by  the  most  excruciating  pain,  profuse  bloody  dis- 
charge, terrible  strangury  and  complete  urinary  retention 
for  twelve  and  twenty-four  hours. 

It  must  be  conceded  that  the  vast  majority  of  genito- 
urinary specialists  are  opposed  to  the  abortive  treatment  of 
gonorrhea:  First,  because  it  does  not  abort,  except  in  a 
small  percentage ;  second,  where  it  fails  to  abort  the  gonor- 
rhea is  generally  aggravated ;  and  third,  it  is  apt  to  lead  to 
painful  and  serious  complications. 

I  also  am  opposed  to  it,  as  a  general  thing.  And  still 
there  are  special  cases  where  we  are  fully  justified  in  making 
an  attempt  to  abort  the  disease,  and  in  these  special  selected 
cases  we  are  sometimes  rewarded  with  brilliant  successes. 
To  illustrate.  A.  B.,  age  28,  has  had  intercourse  five  days 
before,  and  for  the  last  forty-eight  hours  has  had  an  un- 
comfortable, ''hot"  and  itchy  sensation  in  the  anterior  por- 
tion of  the  urethra.  This  morning  he  noticed  a  small  drop 
of  discharge.  By  gentle  pressure  we  succeed  in  expressing 
another  drop,  which  when  examined  shows  the  presence  of 
numerous  unmistakable  gonococci.  (An  examination  of  the 
woman  the  following  day  shows  her  to  be  suffering  with  a 
chronic  gonorrhea.)  He  has  had  gonorrhea  five  years  be- 
fore, but  was  completely  cured,  and  his  urine  has  been  free 
from  shreds.     Even  now  the  urine — not  only  the  second  but 


ABORTIVE  TREATMENT  121 

also  the  first  portion,  with  the  exception  of  the  first  few 
drops — is  perfectly  limpid  and  free  from  shreds.  To  the 
suggestion  that  locally  it  would  be  best  to  wait  a  day  or 
two,  he  replies  no,  that  he  must  be  cured  as  soon  as  possible, 
for  he  is  to  get  married  in  two  weeks.  The  possible  dangers 
of  an  abortive  course  of  treatment  are  explained  to  him, 
but  he  is  willing  to  take  all  the  risks.  He  is  then  treated 
with  protargol,  by  the  method  to  be  here  outlined ;  the  dis- 
charge and  the  burning  increase  at  first,  but  at  the  end  of 
five  days  the  man  is  completely  cured;  no  discharge,  no 
gonococci,  the  urine  perfectly  clear,  and  the  marriage  is 
followed  by  no  disagreeable  consequences  whatever. 

Admitting  then  that  there  are  cases  in  which  an  attempt 
at  abortive  treatment  is  justifiable  and  even  indicated,  what 
is  the  best  method?  Silver  nitrate  should  never  he  used  for 
the  purpose.  In  weak  dilutions  it  is  inefficient,  in  strong 
solutions  it  is  dangerous.  Not  that  we  may  not  succeed 
occasionally  in  aborting  a  case  with  silver  nitrate,  but  the 
percentage  of  such  smooth  successes  is  so  small  and  the 
danger  of  aggravating  the  trouble  and  causing  painful  com- 
plications is  so  great,  that  we  have  no  right  to  use  this 
method.  Brutal  and  risky  measures  are  occasionally  suc- 
cessful, but  that  does  not  mean  that  we  have  a  right  to 
sanction  them. 

There  are  several  drugs  that  have  been  used  in  the  abor- 
tive treatment  of  gonorrhea ;  but  we  will  not  waste  time  in 
describing  them  all;  we  will  limit  ourself  to  the  two  with 
which  we  have  had  most  experience ;  they  are  protargol  and 
argyrol.  They  are  a  strong  enough  silver  salts,  but  the 
inflammation  they  produce  is  not  strong  enough  to  result  in 
healing  with  cicatricial  contraction.     Now  for  the  method : 


122     GONOERHEA  AND  ITS  COMPLICATIONS 

The  patient  urinates  and  the  anterior  urethra  is  gently 
washed  out  with  about  four  ounces  of  warm  normal  salt 
solution  (7:1000).  No  force  must  be  used,  and  not  more 
than  a  dram  or  two  of  solution  should  be  at  any  time  in  the 
urethra  (so  as  to  prevent  any  fluid  from  opening  the  cut-off 
muscle  and  penetrating  into  the  posterior  urethra),  and  the 
meatus  should  not  be  tightly  closed  by  the  tip  of  the  syringe, 
so  that  the  fluid  may  flow  freely  back  A  few  drops  (5  to 
10)  of  a  4  per  cent,  solution  of  cocaine,  eucaine  or  alypin 
are  then  instilled  into  the  urethra.  One  dram  of  a  2  per 
cent,  protargol  solution  is  then  injected,  and  by  closing  the 
meatus  with  the  fingers  held  in  for  five  minutes.  In  three 
hours  a  dram  of  a  1  per  cent,  solution  of  protargol  is  in- 
jected and  held  in  for  three  minutes.  This  injection — 1 
dram  of  a  1  per  cent,  protargol  solution  held  in  for  three 
minutes — is  repeated  every  two  hours  until  four  injections 
have  been  given.  The  next  four  injections,  at  three  hour 
intervals,  are  given  with  1/2  per  cent,  solutions ;  and  the  next 
four  injections,  also  at  three  hour  intervals,  are  given  with 
1/4  per  cent,  solutions.  If  we  use  argyrol,  the  method  is  the 
same,  only  the  strength  of  the  solution  is  different.  The 
initial  solution  is  50  per  cent.,  and  the  subsequent  solutions 
25  or  20  per  cent. 

The  discharge  is  examined  for  gonococci  every  day.  At 
the  end  of  two  or  three  days  we  know  what  we  may  expect. 
If  the  abortive  treatment  proves  successful  and  the 
gonococci  have  disappeared  or  are  becoming  less  and  less, 
well  and  good.  If  not,  then  also  well,  though  not  so  well; 
at  any  rate  we  have  not  hurt  our  patient,  and  we  may  then 
proceed  with  the  regular  treatment  of  acute  gonococcal 
urethritis. 


ABORTIVE  TREATMENT  123 

When  not  to  attempt  the  abortive  treatment. — ^While 
there  are  differences  of  opinion  among  urologists  as  to 
whether  abortive  treatment  should  ever  be  tried  or  not, 
there  is  practically  no  difference  of  opinion  as  to  when  it 
should  not  be  attempted.  All  agree  that  abortive  treatment 
should  not  be  attempted  if  the  discharge,  no  matter  how 
scanty,  has  lasted  longer  than  forty-eight  hours ;  nor  if  the 
discharge  is  profuse  and  purulent,  no  matter  of  how  short 
duration;  nor  when  the  meatus  is  red,  puffed  and  swollen; 
nor  when  the  glans  is  turgid ;  nor  when  there  is  a  consider- 
able burning  on  urination ;  nor  when  there  are  the  slightest 
signs  of  strangury ;  nor  when  the  patient  is  suffering  with 
painful  erections  or  chordee.  It  is  too  late  then  to  attempt 
abortive  treatment,  and  that's  all  there  is  to  it;  and  besides 
all  the  patient 's  symptoms  are  almost  sure  to  become  greatly 
aggravated. 


CHAPTER  XXI 

THE  PREVENTION  OF  GONORRHEA 

I  confess  that  it  is  with  a  feeling  of  reluctance  and  dis- 
pleasure not  unmixed  with  some  disgust  that  I  approach  the 
task  of  writing  this  chapter.*  I  would  like  it  much  better 
if  it  did  not  have  to  be  written.  It  would  be  infinitely 
better  if  things  were  so  arranged  in  this  world  that  no 
necessity  existed  for  the  use  of  venereal  prophylaxis. 
A^Tiether  it  would  not  be  better  for  the  world  at  large  if 
people  avoided  illicit  relations  altogether,  thus  escaping 
practically  all  danger  of  venereal  infection,  is  a  question 
the  discussion  of  which  does  not  belong  within  the  scope 
of  this  book.  I  discussed  it  elsewhere  and  shall  discuss  it 
again.  But  the  fact  remains  that  people  do  indulge  and  in 
spite  of  all  preaching  will  indulge  in  illicit  relations,  not 
only  antemarital  but  also  extramarital.  So  the  question 
arises :  Should  we  refuse  them  any  protection  and  permit 
them  to  infect  themselves,  carrying  perhaps  the  infection 
to  their  wives  and  children,  or  should  we  teach  them  how  to 
take  care  of  themselves,  so  that  the  venereal  scourge  may 
eventually  be  limited  instead  of  constantly  increasing  in  ex- 
tent?    I  believe  in  the  latter.     The  idea  that  illicit  inter- 

*  Logically,  the  chapter  on  prevention  should  precede  the  chapter 
on  cure.  Unfortunately,  however,  most  men  apply  to  us  after  they 
have  gotten  the  disease,  and  not  before,  and  to  many  physicians  the 
subject  of  prevention  of  gonorrhea  will  possess  but  an  academic  in- 
terest. 

124 


THE  PREVENTION  OF  GONORRHEA        125 

course  is  a  crime  for  which  venereal  disease  is  a  well  de- 
served punishment  is  entirely  too  mediaeval,  too  brutal  to 
meet  with  my  acceptance.  Led  to  its  logical  conclusion, 
this  idea  would  consider  any  physician  who  treats  venereal 
disease  a  criminal,  because  by  curing  patients  of  their 
''deserved"  diseases  he  encourages  immorality.  Only  a 
man  of  the  mental  caliber  of  a  mediaeval  monk  could  sub- 
scribe to  such  a  belief.  The  humanitarian  physician  must 
not  only  cure,  he  must  prevent  disease,  and  he  recognizes 
that  prevention  is  vastly  more  important  than  cure. 

I  wish  the  remedies  we  do  have  were  more  satisfactory 
than  they  are ;  then  this  book  would  not  have  to  be  written. 
Not  that  the  remedies  that  we  have  are  not  efficient.  But 
they  are  unesthetic,  some  of  them  are  troublesome,  and  for 
these  two  reasons  people  will  often  neglect  using  them.  If 
properly  used  the  remedies  may  be  said  to  be  absolute  pre- 
ventives ;  but  the  trouble  is  that  people  will  either  not  use 
them  or  use  them  improperly.  Truthfully  speaking,  the 
fault  is  not  in  the  prophylactics  but  in  the  people,  but  still 
if  the  remedies  were  pleasant  and  easy  of  application  they 
would  be  used  more  certainly  and  more  regularly.  But 
there  has  been  gradual  progress  in  this  direction,  and  we 
may  perhaps  see  an  unexceptionable  prophylactic  in  the 
near  future. 

The  first  principle  of  prophylaxis  is  personal  cleanliness 
of  the  genitals.  A  person  who  seldom  washes  the  glans 
penis  and  allows  smegma  to  accumulate  beneath  his  foreskin 
invites  infection.  The  foreskin  should  be  drawn  back  daily 
and  it  and  the  glans  washed  carefully  with  soap  and  water 
and  dried.  If  there  is  a  tendency  to  abrasions,  washings 
with  alcohol  (1  part  alcohol  and  3  parts  water)  or  with  a 


126     GONORRHEA  AND  ITS  COMPLICATIONS 

5  per  cent,  solution  of  alum  should  be  resorted  to.  Of 
course  no  suspicious  sexual  relations  should  be  had  when 
there  is  the  slightest  abrasion  on  any  part  of  the  penis,  and 
should  the  tendency  to  abrasions,  or  cracks,  or  pimples  per- 
sist, a  physician  should  be  consulted. 

Circumcision  is  an  important  prophylactic  measure,  and 
the  circumcised  have  a  great  advantage  over  the  non-cir- 
cumcised in  respect  to  venereal  infection.  While  the  im- 
portance of  circumcision  is  more  striking  in  avoiding 
chancre  and  chancroids,  still  it  also  plays  a  role  in  avoiding 
gonorrhea.  For  I  am  convinced  that  in  many  cases  the 
gonococcus  is  not  deposited  immediately  in  the  fossa  navicu- 
laris,  but  in  the  preputial  cavity,  whence  it  wanders  at  its 
leisure  into  the  urethra.  The  glans  can  also  be  much  more 
thoroughly  sterilized  when  the  prepuce  is  absent  than  when 
it  is  present. 

A  simple  but  in  many  cases  efficient  prophylactic 
measure  is  urination  immediately  after  coitus.  Many 
men  use  no  other  prophylactic  and  they  seem  to  be 
safe.  While  of  course  it  cannot  be  scientifically  proven 
that  without  this  precaution  they  would  have  contracted 
gonorrhea,  still  the  fact  that  some  men  indulge  in 
promiscuous  intercourse  for  years  without  once  contract- 
ing the  disease  is  some  presumptive  evidence  of  its  value. 
The  stream  of  urine  mechanically  washes  away  the  infective 
material;  and  besides  the  urine,  being  of  acid  reaction, 
acidifies  the  urethral  secretion,  and  this,  as  we  know,  is  an- 
tagonistic to  the  development  of  the  gonococcus.  The  man 
should  have  plenty  of  urine  in  his  bladder  (he  should  drink 
plenty  of  water  and  not  urinate  before  coitus),  and  urinate 


THE  PREVENTION  OF  GONORRHEA        127 

immediately.  The  proper  way  is  to  start  urinating,  then 
to  compress  the  meatus,  and  then  suddenly  let  go.  This 
dilates  the  urethra,  and  the  stream  coming  out  with  more 
force  washes  out  the  canal  more  effectively. 

If  desired  a  dose  of  hexamethylenamine  (5  grains)  and 
monobasic  sodium  phosphate  (about  30  grains  in  a  glass 
of  water)  or  sodium  benzoate  (15  grains)  may  be  taken 
before  coitus.  This  renders  the  urine  more  strongly  acid 
and  also  perhaps  somewhat  antiseptic. 

The  Condom.  The  oldest,  simplest  and  at  the  same  time 
safest  protective  against  gonorrhea  is  the  condom.  This 
mechanical  covering  was  invented  by  a  Dr.  Condom,  who 
may  well  be  considered  one  of  the  benefactors  of  the  human 
race.  It  has  no  doubt  since  its  introduction  protected  mil- 
lions of  people  from  infection.  Prof.  Blaschko  of  Berlin 
has  stated  publicly  that  Dr.  Condom  deserves  a  monument, 
as  without  his  little  invention  all  civilized  races  would 
probably  by  this  time  be  completely  syphilized.  The  con- 
dom (also  called  French  letter,  protector,  skins,  capote 
anglais)  is  made  principally  of  two  materials :  rubber  and 
fish-skins  (that  is  the  swimming  bladders  of  fishes).  Each 
material  has  its  advantages  and  disadvantages.  The  rubber 
is  supple  and  elastic,  fits  better  and  does  not  easily  slip  off. 
But  being  a  vegetable  material  it  forms  a  barrier,  and 
diminishes  to  a  great  extent  the  voluptas  of  the  act.  In 
some  men  it  interferes  with  erection  and  ejaculation.  And 
some  men  detest  them  so  that  they  would  rather  forego  all 
sexual  relations  than  to  use  one.  The  skin  condoms  do  not 
affect  the  act  so  much,  but  are  not  elastic,  and  must  be 
moistened  before  use.     Condoms  are  also  made  from  the 


128       GONORRHEA  AND  ITS  COMPLICATIONS 

cecum  of  sheep  and  they  have  the  same  advantages  and  dis- 
advantages of  those  of  fish-skin.*  Of  course  only  the  best 
quality  of  condom  should  be  purchased,  and  one  should 
make  sure  that  the  condom  is  perfect,  by  blowing  it  up  or 
filling  up  with  water  before  use.  For  the  benefit  of  people 
in  moderate  circumstances  it  may  be  stated  that  condoms 
of  good  quality  may  be  used  more  than  once,  but  of  course 
they  must  be  cleansed  and  disinfected  after  each  use.  Wash 
well  in  running  water  and  then  let  it  soak  in  a  solution  of 
mercuric  chloride  1  ;1,000  for  an  hour  or  two,  wipe  and  dry 
and  put  away  wrapped  up  in  gauze. 

Condom  No  Protection  for  Syphilis.  While  this  book 
deals  exclusively  with  gonorrhea,  still  I  consider  it  a  matter 
of  duty  to  emphasize  that  while  a  good  condom  is  a  protec- 
tion against  gonorrhea,  it  is  not  a  protection  against  syphilis. 
I  have  had  in  my  practice  a  number  of  cases  of  syphilis  con- 
tracted by  patients  who  used  condoms.  Not  to  mention  the 
possibility  of  infection  from  mucous  patches  on  the  lips, 
which  is  self-evident,  infection  may  take  place  either  at  the 
root  of  the  penis  or  on  the  scrotum.  Only  this  morning 
(March  19,  1915)  I  saw  a  patient,  sent  to  me  by  Dr.  R.  I. 
Tillman,  with  a  typical  chancre  at  the  root  of  the  penis  and 
a  well  developed  roseola  over  the  entire  body.  Some  five 
weeks  ago  he  had  sexual  relations  with  a  prostitute.  He 
used  a  condom,  but  the  chancre  developed  at  the  very  root 
of  the  penis,  the  part  unprotected  by  the  condom.  We 
have  no  real  reliable  preventive  against  syphilis. 

Chemical  Antiseptics.     We  now  come  to  chemical  anti- 

*  We  understand  that  at  present  all  so-called  fish-skins  are  made 
from  the  cecum  of  sheej^,  so  that  the  correct  term  is  really  cecal 
condoms. 


THE  PREVENTION  OF  GONORRHEA        129 

septies.  One  of  the  simplest  and  cleanest  is  a  solution  of 
mercuric  chloride  (corrosive  sublimate)  1  to  5,000.  Many 
men  carry  a  small  vial  of  this  solution  with  them,  and  with 
a  piece  of  cotton  wash  thoroughly  the  glans  and  squeeze  a 
few  drops  into  the  open  meatus.  Some  have  told  me  that 
they  had  been  using  it  for  years  without  ever  any  accident. 
It  is  clean,  cheap  and  does  not  stain  the  clothes.  Some 
people,  however,  are  sensitive  to  mercuric  chloride  and  the 
solution  causes  some  irritation  on  the  glans  or  in  the  ure- 
thra. 

Others  use  a  solution  of  potassium  permanganate  (1  to 
5,000)  by  injection.  Guiard  is  particularly  partisan  to  this 
method.  About  two  to  four  drams  is  injected  with  a  hand 
syringe,  retained  for  a  few  minutes  and  let  out,  and  the  pro- 
cedure is  repeated  several  times  (5  to  10  times).  This 
method  is  effective  as  a  prophylactic,  but  I  am  not  in  favor 
of  it.  By  injection  the  infecting  material  may  be  carried 
further  backward,  injections  are  irritating  and  may  cause 
damage,  and  besides  potassium  permanganate  stains  the 
clothes  and  linen.  The  use  of  oxycyanide  of  mercury  would 
obviate  the  last  objection,  but  there  would  still  remain  the 
objections  inherent  in  all  injections  in  the  layman's  hands. 
I  have  had  several  accidents  from  the  use  of  injections  and 
therefore  do  not  recommend  them. 

Protargol  and  argyrol  have  been  used  extensively  and 
effectively  as  venereal  prophylactics.  A  few  drops  of 
a  5  or  10  per  cent,  solution  of  protargol  or  20  per 
cent,  solution  of  argyrol  are  instilled  into  the  urethra 
and  held  there  for  several  minutes.  In  some  cases  a 
slight  urethritis  is  caused  by  these  strong  solutions,  but 
the  urethritis  is  readily  controlled,  and  weaker  solutions  are 


130       GONORRHEA  AND  ITS  COMPLICATIONS 

used  on  future  occasions  or  a  different  combination  is  sub- 
stituted. 

Silver  nitrate  is  efficient,  but  is  too  irritating  and  I  am 
opposed  to  its  use. 

In  the  last  few  years,  following  MetchnikofP's  experi- 
ments, calomel  in  ointment  form  has  been  used  a  great  deal 
as  a  prophylactic  against  syphilis.  It  has  been  found,  how- 
ever, that  the  calomel  ointment  also  acts  as  a  preventive 
against  gonorrhea  and  some  advise  the  use  of  it  as  a  general 
venereal  prophylactic.  The  glans  and  prepuce  is  well 
rubbed  in  with  the  calomel  ointment  to  prevent  the  de- 
velopment of  sj^hilis  and  chancroids,  and  some  of  it  is  in- 
jected into  the  urethra  and  this  prevents  the  development  of 
gonorrhea.  The  preparation  used,  for  instance,  on  the 
U.  S.  SS.  Rainbow  has  the  following  formula : 

Calomel  50  gm. 

Liquid  petrolatum 80  c.c. 

Adeps  lanae 70  gm. 

This  being  a  semi-liquid  preparation,  it  can  be  injected 
with  an  ordinary  urethral  syringe.  During  a  period  of 
six  months  there  were  529  admitted  exposures,  with  the 
development  of  only  four  cases  of  gonorrhea.  Of  these  four 
one  denied  exposure  and  therefore  did  not  receive  the  treat- 
ment, two  received  it  late,  more  than  twelve  hours  after 
exposure,  so  that  out  of  the  529  there  is  really  only  one 
failure,  which,  considering  the  character  of  the  women  with 
whom  the  sailors  consort,  is  an  excellent  record. 

To  avoid  the  inconvenience  of  having  to  prepare  solu- 
tions, of  carrying  about  a  bottle  and  syringe,  a  number  of 
prophylactics  have  been  put  on  the  market,  which  have  the 


THE  PREVENTION  OF  GONORRHEA        131 

advantage  of  small  compass,  cleanliness,  and  readiness  for 
use.  Every  country  has  its  own  preparations — in  Germany 
there  are  dozens  of  them.  Most  of  them  contain  20  per 
cent,  solutions  or  mixtures  of  protargol,  some  contain  al- 
bargin,  some  oxycyanide  of  mercury:  Viro,  Selbstschutz, 
Samariter,  etc.  There  are  several  in  this  country,  but  the 
best  known  are  the  Sanitubes  ( and  the  ' '  K  ^ '  packet ) .  Their 
use  is  very  simple,  and  as  full  instructions  for  use  accom- 
pany these  preparations,  there  is  no  need  of  giving  them 
here. 

Antiseptic  Douches.  Another  very  important  measure, 
but  one  which  does  not  concern  the  man,  is  for  the  woman 
to  take  a  copious  antiseptic  douche  (mercuric  chloride 
1:5000)  immediately  before  coitus,  or  as  near  before  as 
possible.  This  measure  alone  properly  used  would  act  as 
an  efficient  prophylactic  in  a  very  large  percentage  of 
cases.  I  hesitate  to  say  how  large,  but  my  opinion  is  in 
about  90  per  cent.  That  it  would  also  protect  the  woman 
against  infection  from  the  man  is  self-understood.  Many 
prostitutes  using  this  precaution  go  on  plying  their  trade 
for  years  without  acquiring  any  disease ;  and  on  the  other 
hand  many  prostitutes  and  semi-prostitutes  who  are  dis- 
eased, by  the  simple  method  of  using  a  copious  douche  be- 
fore coitus  avoid  giving  infection  and  are  thus  able  to  keep 
their  customers.  It  is  for  this  reason  that  the  professionals 
are  often  less  dangerous  than  the  "occasional"  loose  girls, 
because  the  former  have  the  knowledge  and  the  facilities 
for  using  prophylactic  measures  which  the  latter  have  not. 

The  above  are  the  positive  measures  for  the  prevention  of 
gonorrhea.  But  he  who  wishes  to  avoid  the  disease  must 
also  listen  to  some  negative  advice.     Besides  several  things 


132       GONORRHEA  AND  ITS  COMPLICATIONS 

to  do,  there  are  also  several  things  not  to  do.  The  most 
important  of  all  Don'ts  is:  Don't  drink  any  alcohol,  in 
any  shape  or  form.  Alcohol  is  a  great  ally  of  venereal  dis- 
ease. It  has  a  doubly  pernicious  effect.  It  weakens  the 
reasoning  power,  paralyzes  the  will,  and  thus  causes  the 
man  to  lose  all  prudence,  making  him  tarry  at  the  act  or 
repeat  it  too  many  times,  and  prevents  him  often — by  put- 
ting him  into  a  deep  sleep  lasting  several  hours — from  em- 
ploying any  antiseptic  measures.  But  besides  this,  alcohol 
by  producing  a  congestion  in  the  urethral  canal  makes  it 
more  vulnerable  and  more  receptive  to  infective  agents.  If 
no  alcoholic  beverages  were  indulged  in,  there  would  be  not 
only  much  less  sexual  indulgence,  but  also  very  much  less 
venereal  disease.  Bacchus  is  not  only  the  greatest  friend 
of  Venus,  but  also  of  Mercury  (and  should  I  say  Silver?). 

Another  Don't  is  not  to  tarry  too  long  in  the  act,  not  to 
attempt  to  prolong  it  unnecessarily,  and  not  to  repeat  the 
act  unless  another  antiseptic  douche  has  been  taken.  The 
man  who  has  studied  anatomy  can  derive  some  benefit  from 
the  knowledge  that  the  two  most  dangerous,  because  most 
frequently  infected  points  in  woman  are  the  urethra  and 
the  cervix.  The  vagina  is  very  rarely  infected.  Having 
this  knowledge  he  should  guide  himself  accordingly. 

As  is  seen,  there  is  no  royal  road,  no  short  cut,  to  venereal 
prophylaxis.  Pronouncing  a  prayer  or  a  shibboleth  will 
not  do  it.  Some  care  must  always  be  exercised,  some  trouble 
cannot  be  avoided.  But  this  is  a  small  price  to  pay  for 
freedom  from  venereal  disease. 

To  summarize :  In  order  to  avoid  venereal  infection  the 
genital  organs  must  be  kept  in  a  clean,  healthy  condition. 
A  condom  of  the  best  quality  is  up  to  the  present  day  the 


THE  PREVENTION  OF  GONORRHEA        133 

surest  and  simplest  prophylactic.  As,  however,  it  inter- 
feres with  the  voluptas  of  the  act,  some  men  not  being  able 
to  obtain  an  erection  or  ejaculation,  other  measures  become 
necessary.  They  are :  immediate  urination  after  coitus,  and 
instilling  into  the  urethra  a  solution  or  a  mixture  of  pro- 
targol  or  argyrol  or  a  soft  ointment  of  calomel.  The  K 
Packets  and  the  Sanitubes  are  trustworthy  and  can  be 
recommended.  (As  a  protection  against  syphilis,  which 
subject,  however,  does  not  belong  in  this  book,  the  glans 
and  prepuce  should  also  be  well  rubbed  in  with  a  strong 
calomel  ointment.)  The  woman  should  always  take  a 
douche  of  bichloride  of  mercury  before  coitus.  Alcohol  in 
any  form  is  injurious  and  should  not  be  indulged  in  before 
coitus,  nor  should  the  act  be  unduly  prolonged.  Following 
out  these  instructions,  a  man  may  be  pretty  certain  of  never 
contracting  any  gonorrheal  urethritis. 


CHAPTER  XXII 

THE  MINOR  COMPLICATIONS  OF 
GONORRHEA 

PHIMOSIS 

Phimosis  is  a  term  applied  to  a  condition  of  narrowing 
of  the  opening  of  the  prepuce,  so  that  it  cannot  be  retracted, 
and  the  glans  penis  cannot  be  uncovered.  The  term  is  de- 
rived from  the  Greek  phimosis,  which  means  muzzling,  from 
phimos,  a  muzzle.  It  is  quite  an  appropriate  term,  for  in 
many  instances  the  glans  is  effectually  muzzled,  so  that  the 
mouth  of  the  penis,  the  meatus,  cannot  be  seen  or  ap- 
proached, except  with  the  greatest  difficulty. 

The  condition  of  phimosis  is  often  congenital,  occasionally 
traumatic,  and  frequently  the  result  of  the  venereal  dis- 
eases: chancres,  chancroids,  and  urethritis.  It  is  with  the 
latter  variety  of  phimosis  that  we  are  principally  concerned 
here. 

This  condition  of  phimosis  is  apt  to  supervene  in  pa- 
tients whose  prepuce  is  generally  somewhat  narrowed,  and 
in  cases  of  hyperacute  urethritis.  The  inflammation  and 
resulting  edema  infiltrate  the  prepuce  to  such  an  extent 
that  it  cannot  be  retracted.  The  urethral  discharge  and  a 
few  drops  of  urine  after  each  act  of  urination  accumulate 
behind  the  prepuce,  and  frequently  produce  a  balanitis  and 
a  balanoposthitis.     In  severe  cases  the  meatus  itself  be- 

134 


MINOR  COI^IPLICATIONS  OF  GONORRHEA       135 

comes  corroded  by  tlie  accumulated  discharge.  The  suc- 
cessful treatment  of  urethritis  in  the  presence  of  phimosis, 
especially  of  some  severe  degree,  becomes  impossible,  and 
that  condition  must  therefore  first  be  removed.  And  be- 
sides the  glans  itself  is  in  danger  of  ulceration  and  even 
sloughing. 

Treatment.  Gentle  measures  are  at  first  to  be  tried,  and 
in  95  per  cent,  of  cases  they  will  succeed.  If  the  patient 
can  stay  at  home,  he  should  soak  the  penis  every  hour,  for 
fifteen  minutes  at  a  time,  in  a  warm  25  per  cent.  Burrow's 
solution  (Liquor  Burrowi,  1  part,  hot  water  3  parts)  or  in 
a  1 :1000  chinosol  solution.  He  may  at  the  same  time  in- 
ject some  of  the  same  solution  beneath  the  prepuce.  This 
will  keep  the  glans  clean  and  prevent  the  pus  and  urine 
from  accumulating.  If  the  patient  cannot  stay  at  home,  he 
should  wrap  the  penis,  beginning  with  the  glans,  in  band- 
ages dipped  in  the  just  mentioned  solutions  or  in  lotio 
plumbi  et  opii.  The  bandage  should  be  changed  three  to 
four  times  a  day.  Injecting  some  sterilized  sweet  oil  con- 
taining half  a  per  cent,  of  salicylic  acid  between  the  prepuce 
and  the  glans  will  also  prove  an  aid  in  retracting  the 
prepuce. 

After  the  phimosis  has  been  reduced,  any  pathologic  con- 
dition that  may  be  found,  such  as  balanitis,  ulceration,  etc., 
should  be  treated  by  mild  antiseptic  applications,  or  cauter- 
ization. Anointing  the  glans  with  salicylic  oil  two  or  three 
times  daily  will  act  as  a  curative  and  also  as  a  prophylactic. 

If  these  measures  for  some  reason  or  other  fail  to  produce 
the  desired  effect — ^the  prepuce  may  be  thickly  indurated, 
there  may  be  a  lot  of  smegma  and  concretions,  or  from  ulcera- 
tion the  prepuce  may  have  become  adherent  to  the  glans— 


136       GONORRHEA  AND  ITS  COMPLICATIONS 

we  must  have  recourse  to  operative  measures.  These  meas- 
ures are  circumcision  and  incision.  Circumcision  in  a  state 
of  inflammatory  phimosis  I  only  mention  to  condemn.  Be- 
sides the  ahnost  unavoidable  danger  of  the  infection  of  the 
wound,  the  long  time  required  for  healing,  the  cosmetic 
effect  is  generally  bad.  It  is  hard  to  judge  of  the  proper 
amount  of  tissue  to  remove,  and  the  result  is  an  ugly  scar, 
with  either  too  little  or  redundant  tissue. 

Of  the  incisions  we  have  two  kinds:  either  one  dorsal 
incision  or  two  lateral  incisions.  The  dorsal  incision  has 
the  advantage  of  being  only  one :  it  is  better  to  have  to  deal 
with  one  wound  than  with  two ;  the  lateral  incisions,  which 
give  us  two  flaps,  an  anterior  and  a  posterior,  have  the  ad- 
vantage of  giving  us  a  more  thorough  access  to  the  glans. 
The  prepuce  is  washed  thoroughly  with  a  1  -.3000  bichloride 
solution,  and  the  same  solution,  or  one  somewhat  weaker 
(1:5000)  is  injected  abundantly,  by  the  aid  of  a  long 
pointed  syringe,  between  the  prepuce  and  the  glans.  The 
line  of  the  incision — either  one  on  the  dorsum  or  one  on 
each  side — is  infiltrated  with  a  local  anesthetic  solution 
(cocaine,  alypin,  eucaine  or  novocaine;  see  formulas  for 
inflltration  anesthesia)  and  the  cut  is  made  with  a  bistoury 
or  a  pair  of  scissors.  The  cut  wound  is  compressed  with 
some  gauze  saturated  in  a  1:5000  bichloride  solution  until 
the  bleeding  has  stopped.  It  is  best  not  to  put  in  any 
stitches,  unless  the  bleeding  makes  it  absolutely  necessary. 

When  the  acute  condition  has  subsided,  then  circumcision 
may  be  performed. 


MINOR  CO^JPLICATIONS  OF  GONORRHEA      137 

PARAPHIMOSIS 

Paraphimosis  is  the  opposite  of  phimosis;  it  is  a  term 
applied  to  a  condition  in  which  the  prepuce  is  caught  be- 
hind the  corona  of  the  glans,  at  the  coronary  sulcus,  and 
cannot  be  pulled  forward  over  the  glans.  It  surrounds  the 
penis  like  a  tight  cord.  This  condition  may  become  very 
dangerous,  as  the  glans  becomes  puffy,  edematous,  cyanotic, 
and  unless  relieved  may  become  gangrenous.  It  may  also 
be  extremely  painful,  and  interfere  with  micturition.  For- 
tunately most  cases  are  easily  reducible  by  the  experienced 
physician.  By  digital  manipulation  alone,  the  glans  penis 
may  be  so  compressed  as  to  squeeze  out  all  the  edematous 
infiltration  and  the  blood,  and  then  by  anointing  with  some 
fatty  lubricant  the  prepuce  is  easily  slipped  over.  Or  a 
narrow  rubber  bandage  is  wound  tightly  over  the  penis, 
beginning  with  the  glans,  and  in  a  very  short  time  the 
edema  is  reduced  and  the  glans  slips  in. 

In  no  case  of  paraphimosis  within  my  experience  have  I 
had  to  have  recourse  to  operative  measures,  though  in  some 
cases  quite  a  good  deal  of  manipulation  was  required  before 
reduction  was  effected.  But  there  are  neglected  cases,  in 
which  the  patient  has  permitted  the  condition  to  exist  for 
several  days  before  he  applies  for  medical  aid,  in  which 
the  strangulated  tissues  become  plastically  indurated;  and 
passing  the  hardened  edematous  glans  through  the  hardened 
infiltration  of  the  constricting  prepuce  becomes  an  impossi- 
bility. The  only  thing  to  do  is  to  incise  the  constricting 
band,  in  the  median  line,  on  the  dorsum  of  the  penis.  In- 
troduce a  bistoury  flat  under  the  constricting  band,  then 
turn  it  and  cut. 


138       GONORRHEA  AND  ITS  COjVIP  LI  CATIONS 

If  when  the  patient  comes  to  you,  you  find  the  g^lans 
strongly  cyanotic,  almost  black,  cold  and  turgid,  and  with 
diminished  sensibility,  then  not  much  time  should  be  lost. 
An  attempt  at  reduction  by  inanipulation  should  be  made, 
but  this  failing,  not  much  time  should  be  lost  before  in- 
cising the  constricting  band. 

After  the  reduction  of  the  paraphimosis,  the  glans  and 
the  preputial  cavity  should  be  treated  gently.  Irrigation 
with  a  mild  antiseptic  solution,  or  the  application  of  a  mild 
antiseptic  ointment,  is  indicated. 

BALANITIS 

Balanitis  is  an  inflammation  of  the  glans  penis.  It  is  de- 
rived from  the  Greek  word  halanos,  which  means  acorn,  and 
refers  to  the  shape  of  the  glans.  It  is  often  accompanied 
with,  or  is  the  result  of,  phimosis  and  paraphimosis,  but  may 
occur  independently  as  the  result  of  coitus  with  a  woman 
having  a  nasty  irritating  discharge.  "Where  the  glans  is 
simply  inflamed,  or  covered  with  a  whitish  ointment-like 
secretion,  we  call  it  simple  balanitis;  where  it  is  accom- 
panied with  ulcerations,  we  apply  the  term  ulcerative  bal- 
anitis. 

The  treatment  consists  in  cleanliness,  washing  with  hy- 
drogen dioxide  or  1  per  cent,  resorcin  solution,  applying 
compresses  of  chinosol  1 :1000  solution,  or  bismuth  subgallate 
powder,  or  an  ointment  of  the  following  composition : 

^  Zinci  oxidi 5ii 

Bism.  subnitratis 3i 

Ac.  salicylici gr.  x 

Petrolati  albi  .^i 


MINOR  COMPLICATIONS  OF  GONORRHEA  139 

When  the  inflammation  is  of  a  deeper  grade,  or  is  accom- 
panied with  ulceration,  cauterization  by  means  of  a  5  per 
cent,  silver  nitrate  solution  or  5  per  cent,  copper  sulphate 
solution  may  become  necessary.  It  should  be  taken  as  a 
rule  that  on  a  circumcised  glans  we  can  use  stronger  solu- 
tions than  on  a  non-circumcised  one.  In  the  latter  case, 
edema  with  a  consequent  phimosis  is  apt  to  result. 

Posthitis  is  an  inflammation  of  the  prepuce.  (From  the 
Greek,  posthe — prepuce.) 

Balano-posthitis  is  applied  to  an  inflammation  of  both  the 
glans  and  the  prepuce. 

The  treatment  of  posthitis  and  balano-posthitis  is  prac- 
tically the  same  as  that  of  balanitis. 

Here  we  have  three  affections — phimosis,  paraphimosis 
and  posthitis — which  can  be  completely  avoided  by  timely 
circumcision.  Balanitis  is  also  a  much  rarer  and  a  much 
milder  affection  in  the  circumcised  than  in  the  non-circum- 
cised. And  he  who  has  seen  some  severe  cases  of  phimosis 
and  paraphimosis — which  threaten  the  very  integrity  of  the 
male  organ — will  not  have  much  doubt  that  the  law-giver 
who  ordained  the  circumcision  of  all  male  infants  was  also 
a  pretty  good  hygienist.  And  the  fact  that  more  and  more 
people,  outside  the  Jewish  and  Mohammedan  races,  subject 
themselves  to  circumcision  points  to  the  conclusion  that  the 
hygienic  utility  of  this  measure  is  becoming  universally 
recognized. 

ADENITIS.     LYMPHADENITIS  (Inguinal 
Adenitis.     Bubo) 

In  severe  cases  of  urethritis,  particularly  when  the  pa- 
tient is  obliged  to  do  a  good  deal  of  walking  and  lifting, 


140       GONORRHEA  AND  ITS  CO]\IPLICATIONS 

the  inguinal  glands  are  apt  to  get  inflamed  and  swollen. 
The  complication  is,  however,  not  a  very  frequent  one,  and 
the  swelling  but  very  seldom  proceeds  to  suppuration.  It 
may  be  safely  asserted  that  whenever  suppuration  does  take 
place  it  is  due  to  mixed  infection.  I  have  not  had  a  single 
case  of  gonorrheal  bubo  terminate  in  pus  formation. 

The  treatment  is :  Put  the  patient  to  bed,  apply  hot  com- 
presses of  Burrow's  solution  for  a  few  hours,  afterwards 
apply  a  ' '  resolvent ' '  ointment. 

One  of  the  following  ointments  is  satisfactory : 

^  Ung.  hydrargyri oij 

Guaiacoli   31 

Ung.  belladonnae,  q.  s.  ad §i 

!9  Plumbi  iodidi 3i 

Ung.  potassii  iodidi §i 

If  the  patient  cannot  go  to  bed,  the  same  ointment  should 
be  thickly  applied,  covered  with  cotton  and  oiled  silk,  the 
whole  held  in  place  with  adhesive  plaster.  The  application 
of  a  few  overlapping  strips  of  adhesive  plaster  (without  the 
ointment)  over  the  swollen  glands  is  also  beneficial. 

Lymphangitis  or  inflammation  of  the  lymphatic  vessels  of 
the  penis  is  rare,  but  does  occur  in  superacute  urethritis, 
and  is  to  be  treated  by  rest  and  cold  compresses  of  diluted 
solution  of  aluminium  acetate. 

Spongeitis  is  inflammation  of  the  corpus  spongiosum,  and 
cavernitis  is  inflammation  of  the  corpora  cavernosa.  As 
complications  of  gonorrhea  they  are  Yery  rare.  When  they 
do  occur,  they  are  to  be  treated  with  compresses — hot  or 
cold — of  diluted  aluminium  acetate  solution  (1  to  3). 

Periurethritis  is  an  inflammation  of  the  tissues  surround- 


MINOR  COMPLICATIONS  OF  GONORRHEA      141 

ing  the  urethra.  As  a  rule  it  is  circumscribed  and  the 
abscess  may  point  and  open  through  the  penile  skin.  If  the 
abscess  is  not  incised  but  allowed  to  burst,  a  fistula  may  re- 
main. A  fistula  is  more  likely  to  be  the  result  if  the  abscess 
is  near  the  frenum. 

Cowperitis  is  an  inflammation  of  one  or  both  of  Cow- 
per's  glands.  It  may  point  and  burst  in  the  perineal  re- 
gion, on  either  side  of  the  raphe,  between  the  scrotal  junc- 
tion and  the  anus.  It  may  be  felt  as  a  round  swelling,  the 
size  of  a  pea  to  that  of  a  hazel  nut. 

Treatment,  When  the  mass  feels  indurated  without  any 
sign  of  fluctuation,  all  measures  should  be  taken  to  prevent 
suppuration.  The  measures  are :  massaging  and  expressing 
the  gland  into  the  urethra  (when  its  excretory  duct  is  open), 
copious  irrigations  of  the  urethra  with  potassium  perman- 
ganate solution  (1:4000),  rubbing  in  a  resolvent  ointment 
over  the  perineal  region,  or  painting  the  latter  with  tincture 
of  iodine,  or  applying  to  it  two  or  three  leeches.  But  when 
suppuration  is  present,  or  is  inevitable,  it  is  best  to  incise 
the  abscess,  irrigate  it  and  drain  it,  as  we  thus  avoid  a 
troublesome  perineal  fistula. 

PAINFUL  ERECTIONS  AND  CHORDEE 

It  is  natural  that  the  congestion  and  irritation  of  the 
urethral  canal  should  be  the  cause  of  frequent  and  pro- 
longed erections.  These  are  sometimes  the  bane  of  the  pa- 
tient and  are  the  most  disagreeable  and  most  painful  feature 
of  his  gonorrheal  attack.  While  they  are  most  frequent  at 
night,  they  do  occur  quite  frequently  in  the  daytime,  and  they 
may  be  exquisitely  painful.  If  frequent  and  persistent  in 
the  daytime,  they  put  the  patient  in  an  embarrassing  posi- 


142     GONORRHEA  AND  ITS  COMPLICATIONS 

tion,  so  that  he  may  find  it  difficult  to  attend  to  his  work  in 
the  office,  store  or  factory.  In  the  nighttime  the  erections 
are  frequently  accompanied  by  pollutions,  which  are  slug- 
gish, the  semen  oozing  out  slowly,  and  the  urethral  inflam- 
mation being  aggravated  by  them.  The  erections  fre- 
quently aggravate  the  gonorrheal  inflammation,  and  retard 
the  cure.  A  vicious  circle  is  established,  as  is  so  frequently 
the  case  in  disease.  The  urethral  inflammation  causes  the 
erections,  and  the  erections  aggravate  the  inflammation. 

The  term  chordee  is  sometimes  applied  to  these  erections, 
but  this  is  incorrect.  The  term  chordee  is  properly  applied 
only  to  erections  accompanied  by  a  curving  of  the  penis 
downward.  Sometimes  the  glans  alone  is  pulled  downward, 
sometimes  the  whole  penis  is  arched  in  a  semi-circle,  almost. 
It  is  this  variety  of  erection  which  is  the  most  exquisitely 
painful,  and  is  accompanied  by  slight  hemorrhages,  due  to 
the  stretching  and  tearing  of  the  urethral  mucous  mem- 
brane. It  is  so  painful  that  the  patient  in  his  agony — and 
in  his  foolishness — breaks  it.  That  is,  knowing  of  no 
remedy  and  unable  to  bear  his  suffering,  he  lays  the  penis 
on  a  table  or  a  window  sill  and  deals  it  a  violent  blow  with 
the  fist.  It  breaks  the  chordee,  but  it  also  breaks  the  penis, 
tears  the  urethra,  and  this  is  accompanied  by  bleeding — 
sometimes  severe — and  the  formation  of  a  stricture. 

Treatment.  This,  as  all  other  complications  of  gonorrhea 
(as  well  as  of  any  other  disease)  should  be  prevented  if 
possible,  and  the  anodyne,  demulcent,  antiphlogistic  rem- 
edies which  we  administer  for  the  gonorrhea  also  act  in  the 
direction  of  preventing  or  diminishing  painful  erections, 
pollutions  and  chordee.  But  when  these  complications  are 
present,  we  must  use  some  additional  measures.     Dipping 


MINOR  COMPLICATIONS  OF  GONORRHEA    143 

the  penis  in  hot  water,  as  hot  as  can  be  borne,  or  water  con- 
taining some  lead  and  opium  wash  (solutio  plumbi  et  opii  1 
part,  hot  water  7  parts),  or  a  warm  sitz  bath  (100°  F.  grad- 
ually raised  to  115°  or  120°)  for  5  to  10  minutes,  act  as 
a  prophylactic.  But  when  the  erection  or  chordee  is  actu- 
ally present,  then  dipping  the  penis  in  ice  cold  water,  or 
wrapping  it  in  an  ice  cold  compress,  or  surrounding  it  with 
pieces  of  ice,  is  more  efficient.  A  sixtieth  of  a  grain  (1 
milligram)  of  atropine  sulphate  taken  before  going  to  bed 
is  frequently  quite  effective  in  preventing  any  erections. 
Sometimes  it  is  not.  And  then  we  have  to  give  bromides, 
much  as  I  dislike  them.  Potassium  bromide  is  the  most 
efficient,  but  only  because  it  is  the  most  depressant.  And  I 
like  it  least  of  all  the  bromides.  I  generally  prescribe  the 
strontium  and  sodium  bromides — 30  grains  of  each  per  dose. 
Less  will  hardly  have  any  effect.  The  Burroughs- Wellcome 
effervescent  tabloids  of  triple  bromides  make  an  agreeable 
form  of  administration,  and  are  to  be  preferred  when  we 
have  to  deal  with  delicate  stomachs.  Lupulin,  mono- 
bromated camphor  and  hyoscyamine  are  also  efficient. 
Sometimes  we  must  in  addition  to  these  also  prescribe  some 
morphine,  but  only  in  the  form  of  a  suppository.  Here  are 
the  most  efficient  prescriptions  for  the  purpose : 

^  Lupulini,  gr.  v 

Camphoras  monobrom,  gr.  iij 

Hyoscyaminae  hydrobrom,  gr.  ^/qq 

M.f.  caps.  No.  1.    Tal.  dos.  xij 
S.  One  before  going  to  bed. 

In  obstinate  cases  an  additional  capsule  may  have  to  be 
taken  an  hour  before  going  to  bed. 


144       GONORRHEA  AND  ITS  COMPLICATIONS 

j^  Morphinge  sulph.,  gr.  % 
Ext.  belladonnaB,  gr.  % 
01.  theobrom^,  gr.  xxv 
M.f.  suppos.  No.   1.     Tal.   dos.   vi.     S.     Insert  one    on 
going  to  bed. 

RETENTION  OF  URINE 

It  does  occur  occasionally  in  the  course  of  an  acute 
urethritis  that  the  patient  finds  himself  unable  to  pass 
urine.  This  may  be  due  to  a  sudden  exacerbation  of  the 
inflammation  in  the  posterior  urethra,  in  the  prostate,  in 
the  seminal  vesicles,  to  an  inflammation  of  Cowper  's  glands, 
or  to  the  fact  that  the  patient  had  from  before  a  slight  stric- 
ture. The  inflammation  and  the  edema  around  the  stricture 
occlude  the  lumen  of  the  urethra  and  make  it  impermeable  to 
the  urine.  Not  infrequently  such  a  retention  of  urine  oc- 
curs after  the  not  too  gentle  passing  of  a  sound  or  bougie 
or  a  forcible  or  too  strong  injection.  Under  the  latter  cir- 
cumstances, the  retention  may  also  occur  in  the  course  of 
a  chronic  urethritis. 

The  treatment  of  this  condition,  which  is  very  uncom- 
fortable and  if  lasting  too  long  may  of  course  become 
dangerous,  should  be  of  the  very  simplest  kind.  A  hot  bath, 
the  patient  attempting  to  urinate  in  the  water,  is  often  effec- 
tive. Keeping  the  penis  in  hot  water  may  also  prove  effec- 
tive. If  these  measures  fail,  the  injection  of  a  pint  of  hot 
water  into  the  rectum  generally  succeeds.  In  attempting 
to  pass  the  water  from  the  bowel,  the  urinary  sphincter  also 
relaxes  and  the  patient  urinates.  A  good  dose  of  fluid  ex- 
tract of  hyoscyamus  (5  to  10  minims!)  is  also  useful. 
Where  these  measures  fail,  we  must  catheterize  the  patient, 


MINOR  COIVIPLICATIONS  OF  GONORRHEA      145 

using  a  soft  catheter,  well  lubricated  with  warm  sterile  oil. 
The  urethra  should  first  be  anesthetized  with  alypin  and 
adrenalin.  And  I  might  add  that  the  mere  anesthetization 
of  the  urethra,  by  reducing  the  acute  congestion,  the 
strangury,  and  the  fear  of  pain,  will  often  make  urination 
possible,  and  thus  render  catheterization  unnecessary.  If 
you  do  not  succeed  in  passing  a  soft  catheter,  then  you  have 
a  different  case  to  deal  with  than  a  simple  spasmodic  con- 
traction, an  inflammatory  edema  or  nervousness.  And  the 
case  is  to  be  handled  like  retention  resulting  from  stricture, 
by  passing  a  steel  catheter,  by  gradual  dilatation,  by  passing 
filif orms,  or  by  puncturing  the  bladder,  by  means  of  trocar 
and  cannula. 


CHAPTER  XXIII 

ACUTE  PROSTATITIS 

Acute  prostatitis  is  unfortunately  a  rather  frequent  com- 
plication of  gonoiThea.  There  is  a  great  difference  in  the 
opinions  of  venereologists  as  to  the  frequency  of  it,  some 
putting  it  as  low  as  3  per  cent.,  others  as  high  as  92  per 
cent.  This  apparently  absurd  difference  is  really  more 
apparent  than  real,  some  applying  the  term  prostatitis  to 
the  mildest  inflammation  of  the  prostate,  even  of  a  catarrhal, 
transient  character,  others  applying  the  term  only  to  sup- 
purative prostatitis  and  prostatic  abscess. 

If  we  apply  the  term  prostatitis  to  every  mild  congestion 
or  inflammation  of  the  prostate,  then  we  might  consider  it  a 
natural  accompaniment  of  every  case  of  posterior  urethritis. 
If  we  apply  the  term,  however,  only  to  those  cases  which 
give  decided  subjective  symptoms  and  are  accompanied  by 
an  unmistakable  enlargement  of  the  prostate,  then  I  would 
say  that  the  frequency  is  about  20  per  cent.  I  consider  it 
absurd,  however,  to  apply  the  term  acute  prostatitis  only  to 
those  cases  in  which  the  prostate  is  severely  suppurating, 
or  to  consider  acute  prostatitis  synonymous  with  prostatic 
abscess  as  some  do.  Even  a  prostate  which  secretes  pus  in 
profusion  is  not  a  prostatic  abscess.  When  the  urethra 
secretes  pus  profusely  we  use  the  term  urethritis  and  not 
urethral  abscess.  As  long  as  the  ducts  of  the  prostate  are 
open,  so  that  the  pus  finds  its  way  readily  into  the  urethra, 

146 


ACUTE  PROSTATITIS  147 

we  have  no  right  to  speak  of  prostatic  abscess.  It  is  only 
when  the  prostatic  ducts  become  clogged  so  that  the  pus 
accumulates  in  the  prostate,  and  there  is  perhaps  destruc- 
tion of  tissue,  that  we  have  a  right  to  speak  of  prostatic 
abscess. 

I  said  at  the  beginning  that  prostatitis  is  unfortunately 
a  rather  frequent  complication  of  gonorrhea.  Of  course 
every  complication  is  unfortunate,  but  prostatitis  is  par- 
ticularly so,  because  it  is  that  complication  which  makes 
chronic  gonorrhea  one  of  the  most  obstinate,  sometimes  one 
of  the  most  maddening,  conditions  to  treat.  Any  gonorrhea 
in  which  the  prostate  is  not  involved  is  comparatively 
readily  curable,  for  applications  to  the  urethral  canal  are 
readily  made  and  by  the  modem  methods  of  dilatation-irri- 
gation, and  by  massage,  aided  perhaps  by  vacuum  treat- 
ment, we  can  lure  the  gonococci  from  their  hiding  places 
and  destroy  them,  but  once  the  gonococci  penetrate  the  pros- 
tate then  we  have  an  entirely  different  condition  to  deal 
with.  We  cannot  apply  medication  directly  to  and  into 
the  prostate,  by  no  method  of  massage  can  we  be  sure  to 
express  every  little  subdivision  and  duct  of  the  prostate, 
and  I  am  sure  that  it  was  the  infection  of  the  prostate  that 
made  Ricord  say  that  we  knew  when  a  man  got  gonorrhea 
but  only  the  Lord  knew  when  it  would  be  over. 

Besides  the  much  more  hidden  and  labyrinthine  recesses 
which  the  prostate  presents  to  the  germs,  the  latter  seem  to 
find  a  richer  soil  in  it  than  they  do  in  the  urethra  and  the 
urethral  glands,  and  for  this  reason  it  becomes  so  hard  to 
dislodge  them.  All  those  long  dormant  cases  in  which  the 
man  was  free  from  any  symptoms  for  years,  a  gonorrheal 
attack  suddenly  coming  on  after  drinking  or  sexual  inter- 


148       GONORRHEA  AND  ITS  COMPLICATIONS 

course,  are  cases  of  prostatic  infection.  The  prostate  is 
the  germ's  best  hiding-place,  and  just  as  epididymitis  is  the 
most  important  complication  as  far  as  the  race  is  concerned, 
so  prostatitis  is  the  most  important  complication  so  far  as 
the  wife  is  concerned,  for  infection  of  the  wife  usually  re- 
sults not  from  an  uncured  urethritis  but  from  an  uncured 
prostatitis. 

SYMPTOMS 

The  advent  of  acute  prostatitis  may  be  very  gradual,  so 
that  the  patient  has  practically  no  subjective  symptoms,  or 
perhaps  only  an  aggravation  of  the  symptoms  caused  by  his 
posterior  urethritis.  He  may  feel  greater  discomfort  in  the 
perineum,  a  sense  of  weight  and  dragging  down,  difficulty 
in  sitting,  an  inclination  to  walk  with  spread  legs,  etc.  Or 
the  attack  may  come  on  very  violently.  He  will  feel  a 
terrible  weight  and  heat  in  the  rectum,  become  feverish, 
have  perhaps  a  chill.  In  a  severe  acute  prostatitis  the  tem- 
perature may  go  up  as  high  as  103  or  104.  The  patient  is 
constipated,  and  if  he  moves  his  bowels  the  pain  may  be 
excruciating.  The  urethral  discharge,  if  it  was  present 
before,  frequently  stops  entirely,  though  this  is  not  so  fre- 
quently the  case  as  it  is  with  epididymitis.  Mere  touching 
of  the  perineum  is  painful,  while  the  pain  caused  by  inserting 
the  finger  in  the  rectum  and  touching  the  prostate  is  un- 
bearable. 

The  prostate  feels  hot,  throbbing,  hard,  tense,  and  fills  out 
the  entire  rectal  cavity,  sometimes  to  such  an  extent  that 
defecation  is  not  only  painful  but  impossible  in  some  cases. 
By  sweeping  the  finger  around  the  prostate  you  have  ex- 


ACUTE  PROSTATITIS  149 

actly  the  same  sensation  as  in  examining  the  vagina  during 
labor  when  the  child  is  at  the  outlet  of  the  pelvis. 

Besides  difficult  defecation,  pain  on  urination,  or  partial 
and  sometimes  complete  retention  of  urine,  the  pain  is 
severe  not  only  on  pressure  but  is  spontaneous,  and  the 
patient  asks  for  relief,  which  in  some  instances  can  be  af- 
forded only  by  morphine.  The  pain  instead  of  being  located 
in  the  perineum  and  rectum  may  also  radiate  to  the  small 
of  the  back,  to  the  glans  penis,  testicles  and  thighs.  In- 
stead of  being  uniformly  enlarged  only  one-half  of  the  pros- 
tate may  be  swollen,  the  other  half  being  almost  normal. 

After  lasting  for  several  days  in  about  the  same  condition, 
a  prostatitis  may  pursue  one  of  three  courses.  (1)  It  may 
end  in  complete  resolution;  (2)  it  may  end  in  an  abscess; 
(3)  it  may  pass  gradually  into  chronic  prostatitis.  Neither 
the  first  nor  the  second  termination  is  very  common,  the 
most  common  one  is  the  third. 

TREATMENT 

Put  the  patient  to  bed.  As  a  rule  we  find  him  there,  but 
if  we  do  not  we  should  make  him  go  there.  Local  treatment 
of  the  urethra  should  be  stopped,  though  this  is  not  so  im- 
perative as  it  is  in  epididymitis.  The  internal  treatment  on 
the  contrary,  however,  should  be  continued.  Unless  the 
patient  is  so  sick  that  his  stomach  cannot  stand  anything, 
the  santal  oil  preparations  should  be  continued.  They 
diminish  the  dysuria,  render  the  urine  bland,  and  have  ap- 
parently a  beneficial  effect  on  the  prostatitis  itself. 

Magnesium  sulphate,  in  dram  to  two  dram  doses  four 
times  a  day,  should  be  given  regularly.     This  prevents  con- 


150    GONORRHEA  AND  ITS  COMPLICATIONS 

stipation,  has  a  beneficial  effect  on  the  fever  and  the  toxemia. 
If  the  fever  is  above  101  or  102  and  there  is  severe  head- 
ache, I  invariably  give  some  of  the  synthetic  antipyretics, 
such  as  aspirin,  phenacetin,  antipyrin  or  pyramidon. 
These  not  only  have  a  symptomatic  effect  in  reducing  the 
fever,  relieving  the  headache,  and  making  the  patient  feel 
altogether  more  comfortable,  but  they  also  diminish  the 
pain  in  the  prostate  and  materially  shorten  the  course  of 
the  disease.  In  severe  cases  of  prostatitis  we  can  but  ill 
get  along  without  any  antipyretics.  If  the  pain  in  the 
prostate  is  so  severe  that  the  patient  is  unable  to  sleep, 
restlessly  tossing  about  day  and  night,  we  are  forced  occa- 
sionally to  give  a  hypodermic  of  morphine,  though  I  prefer 
to  give  the  morphine  in  the  form  of  suppositories,  as  fol- 
lows : 

^  Morphinae  sulphatis gr.     J^ 

Ext.  belladonnae gr.     ^ 

01.  theobromae gr.     xx 

Less  than  a  third  of  a  grain  of  morphine  has  no  effect  on 
a  real  case  of  acute  prostatitis  which  demands  an  anodyne. 

Leeches  to  the  perineum  are  favored  by  many  physicians 
and  frequently  give  immediate  relief.  I  believe,  however, 
that  we  can  get  along  without  them.  Ice  to  the  perineum 
is  comforting  and  not  injurious.  When  it  comes  to  rectal 
douches,  however,  I  prefer  hot  water  to  cold.  The  resolu- 
tion seems  to  be  brought  about  more  rapidly  by  the  use 
of  heat  than  by  the  use  of  cold.  It  is  true  that  when  a 
prostatitis  is  to  terminate  in  an  abscess  the  hot  water 
enemas  or  applications  by  means  of  the  psychrophore  will 
hasten  this  often,   but  this  is  no  misfortune,   for  if  an 


ACUTE  PROSTATITIS  151 

abscess  is  to  take  place  and  to  break,  the  sooner  it  is  done 
the  better.  The  hot  water  to  the  prostate  may  be  applied 
as  an  ordinary  enema,  about  6  ounces,  containing  10  drops 
of  laudanum  and  10  grains  of  antipyrin,  being  injected  and 
retained  for  about  ten  minutes;  or  it  may  be  applied  by 
means  of  the  rectal  psychrophore,  hot  water  being  cir- 
culated for  about  ten  minutes. 

Suppositories  of  mercurial  ointment  and  ichthyol  have 
often  been  recommended  and  used,  and  I  have  used  them 
many  times  myself,  but  they  irritate  the  rectum  badly, 
sometimes  very  badly,  and  the  benefit  derived  from  their 
use  seems  to  be  too  small  to  outweigh  the  damage.  I  have 
therefore  given  them  up  altogether,  and  the  only  supposi- 
tory that  I  use  in  acute  prostatitis  is  the  following: 

^  lodoformi  gr.     ij 

Antipyrini   gr.      v 

Morphinas  sulphatis gr.    % 

01.  theobromae gr.    xx 

Sig.    One  3  times  a  day. 

The  morphine  of  course  has  a  tendency  to  constipate,  but 
this  is  overcome  by  the  magnesium  sulphate  which  is  ad- 
ministered through  the  course  of  the  disease. 

Some  of  our  German  colleagues  advise  starting  with  mas- 
sage as  soon  as  the  hyperacute  symptoms  have  subsided.  I 
am  opposed  to  it  in  any  stage  of  acute  prostatitis,  as  it  may 
produce  an  exacerbation  of  the  trouble  or  may  set  up  an 
epididymitis.  Massage  of  the  prostate  is  distinctly  a  meas- 
ure reserved  for  chronic  conditions  of  the  gland.  Of  course 
if  there  are  boggy,  fluctuating  places  in  the  prostate  which 
on  gentle  pressure  produce  a  discharge  of  pus  into  the 


152       GONORRHEA  AND  ITS  CO:\IPLICATIONS 

■arethra,  such,  expression  may  be  performed,  but  this  is 
really  a  different  procedure  from  what  we  ordinarily  un- 
derstand by  massage.  If  by  gently  pressing  the  prostate 
we  are  able  to  express  pus  into  the  urethral  canal  we  should 
do  it  twice  or  three  times  a  day,  following  this  procedure 
by  a  very  gentle  irrigation  with  1-4000  potassium  per- 
manganate or  1-1000  silver  nitrate. 

PROSTATIC  ABSCESS 

If  prostatitis  is  to  terminate  in  an  abscess  all  the  symp- 
toms we  described  become  aggravated.  There  is  a  great 
elevation  of  temperature,  though  some  prostatic  abscesses 
without  fever  have  been  described.  There  is  a  great  in- 
crease in  the  heat,  pain  and  throbbing  of  the  prostate. 
There  is  excruciating  dysuria,  headache,  thirst,  dr^^  throat, 
and  there  may  be  complete  retention. 

The  prostate  may  break  into  the  urethra,  or  into  the 
rectum,  or  into  the  perineum.  Sometimes  it  breaks  in 
both  directions,  into  the  urethra  and  the  rectum  or  per- 
ineum, thus  forming  a  urethral  or  urethro-rectal  fistula. 
When  the  abscess  breaks  spontaneously  into  the  urethra 
there  is  a  great  gush  of  pus,  generally  mixed  with  blood, 
and  this  happy  event  is  followed  by  almost  immediate 
diminution  of  all  the  symptoms. 

If  the  abscess  does  not  break  within  a  day  or  two 
and  the  fever  goes  up  liigh,  the  best  thing  to  do  is  to 
incise  the  prostate  through  the  perineum.  But  if  the 
prostate  points  into  the  rectum  and  there  is  a  distinct 
fluctuating  mass  felt  by  the  finger,  then  it  is  best  for  the 
physician  to  incise  the  prostate  through  the  rectum. 

The  rectum  may  be  irrigated  with  an  antiseptic  or  simple 


ACUTE  PROSTATITIS  153 

saline  solution  until  it  is  absolutely  free  from  any  fecal  mat- 
ter, then  a  bistoury  is  plunged  directly  into  the  fluctuating 
mass,  and  the  prostate  is  expressed  as  much  as  possible. 
The  healing  is  less  troublesome  than  when  the  incision  is 
made  through  the  perineum,  and  this  method  will  be  the 
one  which  the  general  practitioner  will  choose. 

As  we  said  before,  an  acute  prostatitis  may  end  in  two 
or  three  weeks  in  complete  resolution,  so  that  there  is  ap- 
parently no  sign  left  of  the  inflammation.  As  a  rule, 
however,  the  symptoms  subside  gradually  and  the  acute 
prostatitis  passes  over  into  subacute  or  chronic  prostatitis, 
the  discussion  of  which  will  be  taken  up  in  the  next 
chapter. 


CHAPTER  XXIY 

CHRONIC  PROSTATITIS 

Chronic  prostatitis  is  a  very  coimnon  condition.  In  a 
greater  or  lesser  degree  it  is  present  in  a  very  large  per- 
centage of  the  male  population  of  every  civilized  country. 

Causes.  One  of  the  most  important  factors  in  the  etiol- 
ogy of  chronic  prostatitis  is  gonorrhea,  but  gonorrhea  does 
not  play  the  same  relative  role  in  the  causation  of  chronic 
prostatitis  that  it  does  in  the  causation  of  acute  prostatitis. 
In  the  latter  gonorrhea  is  by  far  the  principal  factor ;  other 
causes  play  but  a  subordinate  role.  This  is  not  so  in 
chronic  prostatitis;  while,  as  we  said,  gonorrhea  does  play 
a  very  important  role,  other  factors  are  also  of  great  im- 
portance. Among  those  factors  we  may  enumerate  chronic 
urethritis  of  whatever  origin;  masturbation;  sexual  ex- 
cesses (that  is,  too  frequently  repeated  natural  sexual  inter- 
course) ;  coitus  interruptus;  complete  abstinence,  partic- 
ularly if  accompanied  with  excitation,  mental  or  physical, 
without  gratification  (it  is  remarkable  how  the  over-use, 
abuse,  or  non-use  of  a  function  frequently  leads  to  the  same 
result)  ;  a  steady,  long-continued  sedentary  life;  catheter- 
ization; stricture;  and  long-continued  cystitis. 

A  chronic  prostatitis  following  a  gonorrhea,  or  other 
forms  of  urethritis,  may  be  chronic  from  the  very  start  or 
it  may  be  the  end  stage  of  an  acute  or  sub-acute  prostatitis. 

154 


CHRONIC  PROSTATITIS  155 

Symptoms.  The  symptoms  of  chronic  prostatitis  may 
vary  from  the  mildest  to  extremely  severe.  There  are  cases 
of  prostatitis  which  are  symptomless,  or  practically  symp- 
tomless, and  there  are  cases  which  assume  the  character  of 
a  very  serious  malady. 

It  might  be  asked  how  we  know  that  a  man  has  prostatitis 
if  it  gives  him  no  symptoms  whatever.  Of  late  years  a  good 
many  men  before  getting  married,  or  even  before  becoming 
engaged,  come  to  the  physician  for  a  sexual  examination. 
They  tell  him  that  they  feel  all  right  in  every  way,  that 
there  is  absolutely  nothing  the  matter  with  them,  but  that 
they  want  him  to  make  sure  that  they  are  all  right.  Some 
of  them  may  have  had  a  gonorrhea,  some  of  them  have  abso- 
lutely no  venereal  history.  In  a  certain  percentage  of  these 
men  who  complain  of  no  symptoms  whatever  we  find  on 
examination  distinct  evidences  of  prostatitis.  The  prostate 
is  either  enlarged  and  ''boggy,"  or  only  boggy,  and  on  ex- 
pression we  obtain  a  fluid  which  gives  unmistakable  evi- 
dences  of  a  mild  grade  of  inflammation. 

Pathologically,  the  condition  in  the  prostate  may  vary 
from  a  simple  congestion  to  an  extensive  suppuration.  In 
the  majority  of  cases,  however,  the  symptoms  of  prostatitis 
are  pronounced,  and  may  be  classified  as  local,  sensory, 
urinary,  sexual,  and  general  nervous. 

The  local  symptoms  are  those  that  we  discover  by  an 
objective  examination.  The  prostate  is  usually  enlarged, 
soft,  boggy ;  either  soft  throughout  or  soft  in  some  spots  and 
hard  and  nodular  in  others,  more  than  normally  sensitive 
on  pressure,  and  exudes  a  turbid  lumpy  secretion  on  expres- 
sion. 

The  sensory  symptoms  are  heaviness  and  a  dragging  sen- 


156       GONORRHEA  AND  ITS  COMPLICATIONS 

sation  in  the  perineum,  pain  in  the  prostate  and  perineum, 
and  pruritus  ani  or  itching  around  and  within  the  anus. 
The  patient  cannot  sit  comfortably  for  any  length  of  time 
in  one  place  and  likes  to  shift  his  position.  A  symptom  that 
can  be  frequently  observed  by  the  careful  observer  is  that 
the  patient  when  sitting  down  will  sit  on  the  edge  of  the 
chair,  and  if  the  chair  permits  it,  on  one  buttock  only. 
Walking  is  less  annoying  to  him  than  sitting  or  standing. 
He  feels  most  comfortable  lying  down.  While  the  pain  may 
be  limited  to  the  prostatic  region,  it  may,  as  is  easy  to  un- 
derstand with  an  organ  so  rich  in  nerves  as  the  prostate, 
radiate  to  various  parts  of  the  body,  to  the  testicles,  urethra, 
penis,  thighs,  and  small  of  the  back.  The  pain  may  also 
radiate  to  the  kidneys  and  simulate  the  pain  of  renal  colic. 
Personally,  however,  I  have  not  seen  such  cases;  in  renal 
colic  the  pain  is  too  acute,  too  sharp,  to  be  mistaken  for  the 
dull,  gnawing  pain  of  prostatitis.  Still  some  authorities 
claim  to  have  seen  such  cases. 

A  very  frequent  and  most  annoying  symptom  is  a  leaden 
heaviness  in  the  calves  of  the  legs,  and  also  a  burning  in 
the  soles  of  the  feet.  These  symptoms  make  themselves  par- 
ticularly noticeable  in  the  afternoon,  around  four  o'clock. 
I  have  been  able  to  diagnose  prostatitis  in  a  great  number  of 
cases  from  these  two  symptoms  alone.  With  the  cure  of 
the  prostatitis  these  symptoms  disappear. 

The  Urinary  Symptoms. — One  of  the  most  common 
symptoms  is  the  frequency  of  urination.  The  patients  may 
have  to  urinate  every  two  hours  or  every  hour,  and  if  they 
happen  to  drink  some  irritating  liquid  like  beer,  may  have 
to  urinate  every  fifteen  or  twenty  minutes.  They  also  have 
to  get  up  in  the  night  from  one  to  four  times.     Another 


CHRONIC  PROSTATITIS  157 

symptom  is  the  urgency  of  urination.  There  is  a  difference 
between  frequency  and  urgency.  A  person  may  feel  like 
urinating  frequently,  but  if  he  is  unable  to  urinate  at  a 
certain  time  it  may  cause  him  no  effort  to  retain  his  urine ; 
in  the  case  of  urgency,  however,  when  the  desire  to  urinate 
comes  on  it  must  be  complied  with  instantly  or  the  patient 
is  apt  to  wet  his  underwear.  There  is  a  disagreeable,  per- 
haps scalding,  sensation  on  urinating,  and  there  is  drib- 
bling of  urine  after  the  act.  The  size  and  character  of  the 
stream  is  often  unaffected,  though  as  a  rule  it  is  smaller 
than  usual.  The  urine  itself  is  frequently  turbid,  and  con- 
tains many  bacteria  and  a  large  amount  of  phosphates ;  in 
fact,  phosphaturia  is  one  of  the  most  common  symptoms  in 
prostatitis.  Whether  it  is  a  direct  result  of  the  prostatitis 
or  whether  it  is  caused  by  the  nervous  condition  induced  by 
the  prostatitis  is  an  open  question. 

The  sexual  symptoms  are  briefly  summarized  in  imperfect 
erections  and  premature  ejaculations.  The  libido  may  be 
diminished,  but  as  is  so  often  the  case  whenever  any  irrita- 
tive condition  exists  in  the  prostate,  may  be  greatly  in- 
creased, causing  the  patient  to  indulge  to  excess,  thus  still 
further  aggravating  his  condition. 

The  general  and  nervous  symptoms  produced  by  an  irri- 
tated or  inflamed  prostate  are  literally  legion.  First  there 
is  a  general  irritability,  a  physical  and  psychic  irritability. 
The  patient  responds  much  more  quickly  to  external  stimuli, 
such  as  changes  in  temperature,  and  he  gets  very  easily 
upset  over  little  things.  Then  there  is  a  general  depression. 
This  depression  expresses  itself  not  only  in  a  lack  of  desire 
for  work  and  a  lack  of  interest  for  things,  but  in  a  general 
despondency.     The  patient  may  occasionally  become  deeply 


158     GONORRHEA  AND  ITS  COMPLICATIONS 

melancholic,  and  this  to  such  an  extent  that  he  may  harbor 
suicidal  ideas.  If  the  condition  lasts  long  he  may  become 
a  victim  of  sexual  neurasthenia,  with  its  legion  of  symptoms, 
but  to  discuss  the  latter  here  would  lead  us  too  far  and  we 
must  refer  the  reader  to  special  books  on  the  subject. 

TREATMENT 

While  prostatitis,  as  we  have  seen,  may  be  a  serious  com- 
plication, giving  rise  to  numerous  annoying  symptoms  which 
make  the  patient  wretched,  diminish  or  destroy  his  useful- 
ness, and  may  even  lead  him  to  suicide,  there  is  one  bright 
feature  about  it,  and  that  is  that  it  is  very  amenable  to 
treatment. 

While  we  may  not  change  the  secretion  in  a  suppurating 
prostatitis  to  such  a  degree  that  it  does  not  contain  a  single 
pus  cell,  still  practically  all  cases  of  prostatitis  (and  it  is 
quite  safe  to  leave  out  the  word  practically)  may  be  im- 
proved to  such  an  extent  that  they  will  give  no  symptoms 
and  the  patient  will  not  be  aware  of  their  existence. 

The  treatment  of  prostatitis,  as  of  all  diseases  of  the 
genitourinary  organs,  is  both  general  and  local.  The  pa- 
tient must  guard  against  constipation.  The  diet  must  be 
bland,  strong  spices  and  condiments  being  eschewed,  alco- 
holics must  be  reduced  to  a  minimum,  and  everything  must 
be  done  to  raise  the  general  condition  of  the  patient  from 
below  par  to  par  or  above  par.  Cool  baths  and  douches  are 
useful  for  the  general  system,  but  hot  sitz  baths  are  neces- 
sary for  the  prostatic  condition.  It  goes  without  saying 
that  any  pathological  condition  in  the  urethra,  such  as  a 
posterior  urethritis,  or  a  stricture,  or  colliculitis,  or  a  sem- 
inal vesiculitis,  must  be  treated  concomitantly. 


CHRONIC  PROSTATITIS  159 

Prostatic  Massage.  There  is  one  measure,  however, 
which  is  more  important  in  the  treatment  of  chronic  prosta- 
titis than  all  other  measures  combined,  and  that  is  massage 
of  the  prostate. 

It  is  quite  remarkable  what  rapidly  beneficial  effect  a 
massage  of  the  prostate  will  produce  on  the  patient 's  condi- 
tion, both  local  and  general.  It  constitutes  one  of  the  most 
gratifying  methods  of  treatment  in  the  venereal  specialist 's 
work.  Without  the  patient  being  told  what  the  massage 
was  for,  what  it  was  expected  to  accomplish,  he  will  either 
at  once  or  at  the  next  visit  volunteer  the  statement  that  he 
felt  immediately  better,  that  not  only  did  he  feel  an  improve- 
ment within  the  rectum  and  perineum,  but  he  felt  generally 
better.  In  fact,  even  a  mere  examination  of  the  prostate, 
in  which  you  sweep  the  finger  around  the  gland  to  determine 
its  contour,  size,  and  consistency,  and  in  which  you  do 
hardly  any  expression,  produces  a  beneficial  effect.  There 
is  no  exaggeration  in  saying  that  the  effect  of  prostatic 
massage  is  often  simply  marvelous. 

While  we  are  more  interested  in  facts  and  in  the  effects"* 
of  certain  treatment  than  in  the  explanations  of  the  why  and 
wherefore,  still  the  reasons  for  the  strikingly  beneficial  effect 
of  prostatic  massage  have  always  been  of  great  interest 
to  us.  And  while  we  can  pretty  well  explain  the 
rationale  of  its  action,  further  studies  on  the  subject  are 
certainly  in  order.  Some  reasons  of  this  beneficial  action 
are  self-evident.  Where  the  prostate  contains  a  large 
amount  of  catarrhal  or  purulent  stagnant  secretion,  the  mere 
mechanical  removal  of  this  mass,  which  diminishes  the  size 
of  the  organ,  relieving  pressure  on  neighboring  organs  and 
nerves,  is  beneficial.    Then  the  massage  itself  and  the  re- 


160      GONORRHEA  AND  ITS  COMPLICATIONS 


moval  of  the  secretion  improves  the  circulation  in  the 
prostate  and  in  the  periprostatic  veins  and  lymphatics.  It 
tones  up  its  musculature  so  that  new  blood  reaches  its  vari- 
ous recesses,  and  its  tissue,  as  well  as  its  numerous  nerve 
plexuses,  become  better  nourished. 

Technique  of  Massage.  The  way  to  perform  massage 
properly  and  effectively  is  to  have  the  patient,  standing  with 

his  legs  well  apart,  bend  over  a 
chair  or  the  examining  table, 
firmly  supporting  himself  with 
both  hands.  The  index  finger  of 
the  gloved  hand,  over  which  an 
extra  finger-cot  may  be  put  on, 
well  anointed  with  petrolatum 
(for  rectal  examinations  I  prefer 
petrolatum  to  the  water  soluble 
lubricants),  is  introduced  gently 
into  the  rectum  and  the  prostate 
is  gently  but  firmly  massaged,  first 
from  the  right  side  toward  the 
median  line,  then  from  the  left 

Special  Finger  Cot  for   gi^e  toward  the  median  line,  then 
Massaging  the  Prostate. 

a  few  firm,  pressing  strokes  are 

made  from  above  downward.     Special  pressure  is  applied  to 

any  indurations  that  may  be  encountered,  or  to  any  specially 

soft  spots. 

When  the  massage  is  completed  the  patient  is  told  to  get 
up  gradually  and  slowly  from  his  stooping  position,  and  is 
given  a  glass  to  urinate  in.  The  urine  washes  away  the 
prostatic  secretion. 

This  is  for  ordinary  cases  where  there  is  little  discharge, 


CHRONIC  PROSTATITIS  161 

and  that  cliiefly  catarrhal.  But  where  there  is  much  dis- 
charge and  of  a  purulent  character,  it  is  best  to  have  the 
patient  urinate  first,  then  fill  his  bladder  with  a  2  per  cent, 
boric  acid  solution,  then  massage  him,  then  tell  him  to 
urinate,  and  after  he  urinates  it  is  well  to  instill  into  the 
bladder  a  dram  or  two  of  a  1-1000  solution  of  silver  nitrate, 
instilling  a  few  drops  of  the  same  solution  throughout  the 
urethra.  This  is  to  prevent  any  infection  from  the  prostatic 
secretion. 

Massage  in  the  Horizontal  Position.  Some  physicians 
perform  prostatic  massage  with  the  patient  lying  on  his 
back,  or  even  on  his  side.  I  am  opposed  to  this  position, 
because  it  is  much  more  unsatisfactory  than  the  standing- 
stooping  position.  The  finger  can  never  reach  quite  as  far 
with  the  patient  lying  down  as  with  the  patient  standing  up 
and  pushing  his  prostate  against  the  finger.  Nor  can  the 
physician's  finger  ever  get  such  a  leverage  with  the  patient 
in  the  horizontal  position  as  when  the  patient  is  standing. 
For  the  mere  purpose  of  examination  the  recumbent  posi- 
tion may  be  sufficient,  and  when  the  patient  is  of  an  ex- 
tremely nervous  temperament,  subject  to  fainting  spells, 
that  position  must  sometimes  be  chosen,  but  it  is  never  the 
position  of  choice,  and  we  can  never  be  sure  of  giving  the 
patient  a  thoroughly  satisfactory  massage  in  that  position. 
Another  point,  perhaps  not  of  so  much  importance,  but  still 
of  some  importance,  is  that  when  the  patient  is  stooping 
dowQj  the  secretion,  through  gravity,  has  a  tendency  to  run 
out  of  the  urethra;  in  the  recumbent  position  it  is  sure  to 
flow  back  into  the  bladder. 

Abuse  of  Prostatic  Massage.  There  is  no  therapeutic 
procedure,  beneficent  as  it  may  be,  that  cannot  be  abused  or 


162       GONORRHEA  AND  ITS  CO]\iPLICATIONS 

overdone.  This  is  true  of  massage.  Useful  £is  it  is,  much 
damage  may  be  done  by  it  if  it  is  performed  too  brutally  or 
too  frequently. 

There  must  never  be  a  digging  of  the  finger  tips  into  the 
prostate;  there  must  be  only  a  pressure  with  the  entire 
palmar  surface  of  the  finger.  Too  much  force  must  not  be 
used,  or  the  inflammation  instead  of  being  allayed  may  be 
increased  in  severity,  or  even  necrosis  may  be  caused.  Nor 
must  the  massage  be  performed  too  frequently,  but  here  no 
dogmatic  statement  can  be  made  as  to  what  constitutes  fre- 
quency. Some  patients  can  stand  massage  every  other  day, 
some  only  once  a  week  or  once  in  ten  days. 

Massage  must  not  be  performed  when  there  is  acute  in- 
flammation in  the  prostate  or  an  acute  exacerbation  of  a 
chronic  inflammation. 

Besides  the  aggravation 
in   the   condition   of   the 

^    ^  ^      /-n  ,  , .,      prostate  itself  that  the  too 

Instniment      ( Feleki'a     ^ 

Finger )  for  Massaging  frequently  or  too  brutally 
the  Prostate  performed    massage    may 

cause,  it  may  also  cause  an  epididymitis,  a  seminal 
vesiculitis,  and  even  sciatica.  Not  too  much  zeal 
in  the  best  of  causes ! 

Instruments  for  Massage.  Instruments,  like 
Feleki's  finger,  used  by  inexperienced  physicians 
or  those  with  very  short  fingers,  for  massaging  the 
prostate  are  not  to  be  recommended.  They  are 
dangerous  instruments,  as  unwittingly  too  much 
force  may  be  applied  in  using  them.  For  self- 
massage  by  the  patient,  however,  they  may  be  rec- 
ommended.   There  is  little  danger  that  the  patient 


CHRONIC  PROSTATITIS  163 

may  use  too  mucli  force ;  the  pain  will  prevent  him.  Self- 
massage  is  performed  by  the  patient  while  lying  on 
his  back,  undressed.  He  inserts  the  instrument,  warmed 
and  well  lubricated  with  petrolatum,  into  the  rectum  and 
moves  it  up  and  down,  pressing  gently  on  the  prostate,  for 
a  few  minutes.  This  may  be  repeated  three  times  a  week  or 
even  daily. 

A  Few  Minor  Points.  1.  Some  patients  come  to  the 
office  with  full  recta,  the  feces  pressing  on  the  prostate. 
This  not  only  makes  it  unpleasant  for  the  physician,  not  only 
interferes  occasionally  with  the  proper  performance  of  the 
massage,  but  induces  in  the  patient  a  desire  to  defecate. 
Such  patients  should  be  told  always  to  empty  their  bowels 
before  coming  to  the  physician's  office.  If  they  cannot  do 
it  spontaneously  they  should  take  an  enema. 

2.  Where  the  secretion  from  the  prostate  is  so  profuse  as 
to  run  from  the  urethra,  the  patient  is  instructed  to  support 
himself  with  one  hand  only,  holding  in  the  other  hand  a 
small  glass  under  the  penis  to  catch  the  secretion. 

3.  Be  on  your  guard  and  watch  your  patient  very  care- 
fully when  giving  him  the  first  massage,  for  some  patients 
faint  after  the  first  massage.  Let  the  patient  get  up  from 
his  stooping  position  very  slowly,  make  sure  that  he  is  not 
pale,  and  that  he  has  no  sensation  of  fainting.  If  he  com- 
plains of  a  sense  of  weakness  the  best  thing  is  to  lay  him 
down  on  the  examining  table  or  couch  for  a  few  minutes. 

4.  In  some  obstinate  cases  of  prostatitis  I  have  found  the 
introduction  of  a  potassium  iodide-iodine  suppository  (see 
No.  2  of  the  formulas  below)  followed  by  a  gentle  massage 
for  5  to  7  minutes  very  beneficial.  The  massaging  ap- 
parently causes  a  much  greater  absorption  of  the  K  I 


164       GONORRHEA  AND  ITS  CO]\IPLICATIONS 

and  iodine  than  a  mere  introduction  of  the  suppository. 
Hot  Rectal  Douches.     Another  useful  measure,  but  alto- 
gether secondary  to  massage,  is  the  application  of  hot  water 


Prostatic   Psychrophores 


to  the  rectum  by  means  of  one  of  the  numerous  prostatic 
psychrophores.  This  may  be  done  two  or  three  times  a 
day  for  about  fifteen  to  twenty  minutes  each  time.     The 


CHRONIC  PROSTATITIS  165 

psychrophore  is  best  given  into  the  patient's  own  hands  and 
he  is  shown  how  to  use  it. 

The  hot  rectal  tube  applied  for  about  fifteen  minutes  be- 
fore prostatic  massage  makes  the  latter  more  efficient,  per- 
mitting us  to  express  the  secretion  more  readily.  Supposi- 
tories of  various  composition,  the  formulas  for  which  will 
be  found  below,  also  form  occasionally  a  useful  aid  in  the 
treatment.  A  morphine  and  belladonna  suppository  in- 
serted by  the  patient  before  he  comes  to  the  physician's  office 
is  useful  in  allaying  the  irritability  and  making  the  prostate 
less  sensitive,  and  thus  permitting  us  to  manipulate  it  more 
efficiently  than  we  otherwise  could. 

^  lodoformi,  gr.  i  Morph.  sulph.,  gr.  ^4 

Morph.  sulph.,  gr.  ^4  01.  theobromse,  gr.  xxx 

01.  theobromae,  gr.  xxv  IJ  Bism.  iodo-resorcin- 
M.f.  supp.  No.  1.     Tal.  sulphonatis,  gr.  ij 

dos.  xij  Zinci  oxidi,  gr.  v 

Sig.  One  t.  i.  d.  01.  theobromae,  xxv 

^  Potassi  iodidi,  gr.  ij  I^  Antipyrini,  gr.  v 
lodi  puri,  gr.  }i  Sodii  iodidi,  gr.  iij 

Morph.  sulph.,  gr,  %  01.  theobromas,  gr.  xxx 

01.  theobromae,  gr.  xxx  I^  Morph.  sulph.,  gr.  ^4 

^  Ichthyol,  gr.  ij  Ext.  belladonnae,  gr,  % 

Potassii  iodidi,  gr.  iij  01,  theobrom^,  gr.  xxx 

Where  a  psychrophore  and  the  apparatus  necessary  to  run 
a  current  of  hot  water  are  not  obtainable,  the  patient  may 
inject  into  the  rectum  6  to  8  ounces  of  hot  water,  as  hot  as 
he  can  bear  it,  and  retain  it  for  about  ten  minutes.  Instead 
of  hot  water  a  saline  solution,  or  a  saline  solution  with  5 
grains  of  antipyrin  and  5  grains  of  laudanum,  is  often 


166       GONORRHEA  AND  ITS  COMPLICATIONS 

preferable.  It  is,  however,  well  to  bear  in  mind  that  some 
recta  cannot  bear  repeated  hot- water  injections  without 
severe  irritation,  and  they  cannot  be  continued  for  any 
length  of  time.  The  rectal  psychrophore,  however,  can  be 
borne  without  irritation. 

ATONY  OF  THE  PROSTATE  AND  PROSTATORRHEA 

There  is  a  condition  of  the  prostate  which  deserves  con- 
sideration by  itself,  under  a  separate  subdivision.  It  is  not 
an  inflammation  of  the  prostate  and  no  inflammatory^  prod- 
ucts are  contained  in  its  secretion,  but  the  whole  prostate 
seems  to  be  relaxed,  atonic,  and  this  condition  is  best  de- 
scribed as  atony  of  the  prostate.  Its  ducts  are  dilated  and 
on  mere  touching  of  the  prostate  with  the  finger  a  large 
amount  of  prostatic  secretion  oozes  out  from  the  urethra. 
The  secretion  may  be  quite  normal  or  somewhat  catarrhal  in 
character.  The  symptomis  of  atony  of  the  prostate,  how- 
ever, are  the  same  as  of  the  other  forms  of  prostatitis,  except 
that  the  sexual  features  are  more  markedly  exaggerated. 
Particularly  is  premature  or  precipitate  ejaculation  a  prom- 
inent symptom. 

Prostatorrhea  is  simply  a  further  stage  in  the  development 
of  prostatic  atony.  In  prostatic  atony  the  application  of 
the  finger  produces  a  discharge  of  secretion,  in  prostator- 
rhea the  prostatic  secretion  runs  out  spontaneously  or  at 
the  end  of  micturition  (prostatorrhea  mictionis)  or  after 
defecation  (prostatorrhea  defecationis) . 

The  treatment  of  atony  of  the  prostate  and  of  prostator- 
rhea is  in  general  the  same  as  of  the  other  forms  of  prosta- 
titis.    Massage  plays  here  the  same  important  role.     But 


CHRONIC  PROSTATITIS  167 

instead  of  hot-water  irrigations  or  applications,  cold  water 
is  of  more  benefit.  And  it  is  also  in  this  condition  that 
faradization  with  the  prostatic  electrode  in  the  rectum  and 
the  other  electrode  over  the  symphysis  is  very  useful. 


CHAPTER  XXV 

EPIDIDYMITIS 

Epididymitis  is  an  inflammation  of  the  epididymis.  It 
is  one  of  the  most  frequent,  most  serious,  and  at  the  same 
time  most  preventable  of  all  the  complications  of  gonorrhea. 
It  is  in  fact  a  complication  that,  under  proper  management, 
should  not  happen.  And  if  it  does  happen  rather  too  fre- 
quently in  the  practice  of  a  physician,  we  can  be  quite  cer- 
tain that  it  is  the  physician  who  is  at  fault  and  not  the 
disease.  Strong  injections,  prolonged  irrigations,  meddling 
with  the  urethra,  passing  instruments  in  the  superacute 
stage,  overzealous  massage  of  the  prostate,  are  undoubtedly 
causes  of  epididymitis.  When  I  hear  a  physician  assert,  or 
I  see  one  make  the  statement  in  print,  that  epididymitis  is 
a  complication  in  thirty  per  cent.  (!)  of  all  cases  of  gonor- 
rhea, I  cannot  help  thinking  that  there  is  something  wrong 
with  his  method  of  treatment.  Of  course  the  patient  is 
very  frequently  at  fault;  for  by  walking,  lifting,  working, 
dancing,  drinking,  indulging  in  sexual  intercourse,  strain- 
ing at  stool,  using  injections  forcibly,  etc.,  in  short  by  doing 
things  he  should  carefully  avoid,  he  himself  brings  about  this 
painful  complication,  which  is  so  dangerous  to  the  perpetua- 
tion of  the  race.  And  while  we  are  at  this  point,  we  may  state 
that  it  is  epididymitis  that  renders  gonorrhea  in  the  male  a 
social,  a  racial  disease.  Were  there  no  such  complication 
as  epididymitis,  gonorrhea  would  be  nasty,  painful,  danger- 

168 


EPIDIDYMITIS  169 

ouSj  but  it  would  be  an  individual  disease.  But  on  account 
of  epididymitis,  whicb  renders  thousands  and  thousands 
of  men  sterile,  thus  endangering  the  perpetuation  of  the 
human  species,  the  gonococcus  acquires  the  dignity  of  a 
racial  poison,  and  gonorrhea  that  of  a  racial  disease. 

One  of  the  first  things  the  physician  has  to  bear  in  mind, 
therefore,  when  treating  a  case  of  acute  gonorrhea — and 
also  chronic  for  that  matter — is  to  avoid  everything  and  to 
prohibit  everything  that  may  be  conducive  to  this  com- 
plication. Some  cases  will  occur  in  spite  of  the  utmost 
care.  You  cannot  forbid  the  gonococci  to  penetrate  into  the 
vas  deferens  and  then  into  the  globus  major  or  minor  of 
the  epididymis.  But  these  unavoidable  cases  should  not  be 
more  frequent  than  two  or  three  in  the  hundred.  In  the 
last  nine  years  I  have  not  had  a  single  case  of  epididymitis 
of  my  own  making,  and  I  have  treated  plenty  of  cases  of 
acute  and  chronic  urethritis,  which  goes  to  show  that  with 
care  and  common  sense  you  can  avoid  many  complications. 

SYMPTOMS   AND   COURSE 

When  a  man  has  epididymitis,  he  knows  it.  Sometimes 
he  knows  it  several  hours  before  he  has  the  epididymitis,  by 
a  severe  pain  in  the  groin.  The  pain  in  the  groin  is  par- 
ticularly severe  when  the  spermatic  cord  is  involved  in  the 
inflammation.  As  the  swelling  of  the  epididymis  proceeds, 
the  pain  gets  more  intense  and  the  patient  can  walk  only 
with  great  difficulty.  There  is  a  general  feeling  of  malaise 
(this  feeling  may  precede  the  actual  development  of  the 
epididymitis  by  several  hours),  there  is  fever,  which  may 
go  up  as  high  as  104°  F.,  and  the  patient  feels  undoubtedly 
sick.     Sometimes  you  do  not  have  to  tell  the  patient  to  go 


170       GONORRHEA  AND  ITS  COMPLICATIONS 

to  bed;  he  is  unable  to  do  otherwise.  In  milder  eases  the 
patient  may  be  able  to  walk  about,  but  each  step  is  accom- 
plished with  pain,  and  with  a  terrible  feeling  of  heaviness 
and  dragging  down  in  the  scrotum.  Quite  frequently  the 
patient,  if  of  what  we  call  a  nervous  temperament,  shows  a 
tendency  to  faint.  Occasionally  he  feels  as  if  he  liad  been 
hit  in  the  stomach,  is  nauseated,  vomits,  and  in  some  cases 
there  may  be  convulsions. 

In  acute  gonorrhea  the  onset  of  an  epididymitis  generally 
takes  place  in  the  second  or  third  week,  but  it  may  occur 
as  early  as  the  first  week  or  as  late  as  the  sixth.  When  it  is 
due  to  rude  instinmentation,  to  forcible  injections,  or  to  the 
patient's  carelessness  in  lifting,  dancing,  etc.,  it  may  take 
place  at  any  time. 

Epididymitis  is  usually  unilateral,  but  in  a  large  number 
of  cases  it  is  bilateral.  The  swelling  of  both  epididymes, 
however,  rarely  occurs  at  the  same  time;  usually  one  epi- 
didymis swells  a  few  days  before  the  other.  It  used  to  be 
thought  that  epididymitis  is  more  common  on  the  left  side. 
This,  however,  is  not  so.  In  my  own  practice  I  have  seen 
quite  as  many  cases  of  epididymitis  of  the  right  testicle  as 
of  the  left ;  and  careful  researches  of  other  investigators  give 
the  same  conclusion. 

Whether  epididymitis  occurs  by  direct  extension  of  the 
inflammation  from  the  posterior  urethra  or  prostate,  etc., 
or  whether  it  occurs  by  microbic  invasion,  or  whether  it  may 
occur  through  the  lymphatics,  is  of  little  importance,  and  I 
have  taken  little  interest  in  the  discussions  pertaining  to 
this  question.  In  my  opinion  it  may  occur  in  any  of  the 
three  ways.  The  principal  thing  is  to  know  that  it  occurs 
and  to  know  how  to  prevent  and  to  cure  it.     The  method 


EPIDIDYMITIS  171 

of  its  origin  does  not  influence  its  prophylaxis  or  treatment. 

A  very  peculiar  phenomenon,  which  is  present  in  almost 
every  case  of  epididymitis,  is  the  complete  cessation  of  the 
urethral  discharge  as  soon  as  the  epididymis  swells.  The 
discharge  may  be  ever  so  profuse,  it  almost  invariably  stops 
with  the  establishment  of  this  complication.  Sometimes  it 
stops  several  hours  before.  When  the  epididymitis  subsides 
or  is  cured,  the  discharge  starts  up  again.  The  rationale  of 
this  phenomenon  has  puzzled  urologists  for  many  years,  and 
is  still  puzzling  us.  The  most  likely  explanation  is  that  the 
high  temperature  (104°  F.  or  40°  C.)  either  destroys  or 
deadens  the  gonococci.  This  explanation  would  leave  noth- 
ing to  be  desired,  but  for  the  fact  that  the  cessation  of  the 
discharge  also  takes  place  in  cases  in  which  there  is  a  very 
slight  elevation  of  temperature.  In  its  favor  is  the  fact 
that  a  gonorrheal  discharge  also  often  stops  in  systemic  dis- 
eases accompanied  by  high  temperature. 

The  usual  duration  of  epididymitis  is  one  to  three  weeks. 
It  is,  however,  to  be  borne  in  mind  that  a  not  completely 
cured  epididymitis,  a  nearly  cured  epididymitis,  is  very 
liable  to  relapse;  and  if  a  patient  begins  to  work  or  walk 
about  before  he  is  completely  cured  of  the  acute  attack,  or  if 
injections  and  instrumentation  are  started,  a  recurrence  is 
very  likely,  and  then  the  epididymitis  may  last,  with  greater 
or  lesser  severity,  for  two  or  three  months. 

Gonococcal  epididymitis  very  rarely  ends  in  suppuration, 
much  more  rarely  than  an  epididymitis  due  to  infection  with 
other  bacteria.  But  there  is  one  legacy  that  a  gonococcal 
epididymitis  leaves  much  more  frequently  than  other  kinds 
do,  and  that  is  an  induration  of  the  globus  major  or  globus 
minor  of  the  epididymis,  with  partial  or  complete  occlusion 


172       GONORRHEA  AND  ITS  COMPLICATIONS 

of  tlie  lumen  of  the  vas  deferens.  And  if  this  condition 
occurs  in  both  epididymes,  the  patient  becomes  sterile.  In 
fact  it  is  very  seldom  that  a  gonorrheal  epididymitis  heals 
so  smoothly  as  to  leave  absolutely  no  induration.  Very 
often  the  hardening  in  either  the  globus  major  or  the  globus 
minor  remains  with  the  patient  through  life,  and  by  feeling 
it  we  can  know  absolutely  that  the  patient  has  had  gonor- 
rhea ten  or  twenty  or  thirty  years  before,  when  there  are 
no  other  symptoms  to  indicate  it.  Of  patients  who  suf- 
fered with  unilateral  epididymitis,  about  20  per  cent,  are 
sterile.  Of  those  who  had  bilateral,  from  40  to  45  per 
cent,  remain  sterile.  This  is  natural  and  easy  to  under- 
stand. 

But  there  is  one  phenomenon  that  requires  a  little  dis- 
cussion: People  who  have  had  several  attacks  of  double 
epididymitis  are  less  apt  to  be  sterile  than  those  who  had 
one  attack.  The  reason  is  not  difficult  to  understand. 
When  a  man  has  had  a  double  epididymitis  just  once  and 
never  had  a  recurrence,  it  can  be  readily  assumed  that  the 
lumina  of  his  vasa  deferentia  are  completely  clogged  up,  so 
that  no  gonococci  can  penetrate  them;  in  short,  the  way  is 
completely  blocked.  People  who  have  recurrent  epididy- 
mitis show  by  this  fact  alone  that  their  vasa  deferentia  are 
permeable  to  a  certain  extent  to  noxious  agents,  ^nd  so 
permeable  the  other  way  to  spermatozoa.  It  is  also  quite 
likely  that  a  recurrent  attack,  in  subsiding,  causes  the  reso- 
lution or  absorption  of  some  of  the  inflammatory  products 
of  the  first  inflammation,  and  this  causes  the  previously 
obstructed  lumen  to  become  permeable.  I  have  had  two 
very  instructive  cases  in  brothers,  which  will  be  found  re- 
ported later  on. 


EPIDIDYMITIS  173 

TREATMENT 

The  first  and  most  important  thing  is  to  put  the  patient 
to  bed.  As  stated  before,  in  many  cases  the  physician  does 
not  have  to,  because  the  patient  is  unable  either  to  sit  or  to 
stand.  Even  in  cases  in  which  the  patient  is  able  to  walk, 
he  ought  to  be  put  to  bed,  for  an  apparently  mild  epididy- 
mitis may  in  a  few  hours  become  a  very  formidable  one, 
and  it  is  just  the  walking  and  being  about  that  may  change 
it  from  the  former  into  the  latter  We  know  that  there 
are  cases  in  which  it  is  impossible  for  the  patient  to  go  to 
bed ;  by  doing  so  he  may  risk  losing  his  position,  his  bread 
and  butter.  There  we  have  to  do  the  best  we  can,  but  that 
does  not  mean  that  it  is  right.  The  patient  simply  chooses 
what  is  to  him  the  lesser  of  two  evils,  but  this  choice  has  not 
the  sanction  of  medical  science.  It  is  only  too  often  that 
medical  science  finds  itself  opposed  by  economic  conditions, 
and  under  our  present  economic  system  it  is  the  patient's 
economic  condition  that  conquers.  But  medicine  must  not 
cease  to  protest,  and  it  must  keep  up  this  protest  until  such 
time  as  the  dicta  of  medicine  shall  be  supreme,  both  in  the 
prevention  and  the  cure  of  disease. 

So,  then,  the  patient  is  put  to  bed  and  the  testicles  are 
elevated.  To  accomplish  this  in  the  simplest  manner,  we 
put  a  broad  strip  of  adhesive  plaster  across  the  patient's 
thighs,  close  under  the  scrotum,  and  on  this  plaster  the 
scrotum  rests  comfortably  as  on  a  shelf-.  The  scrotum  and 
the  thighs  are  shaved.  This  makes  the  removal  of  the 
plaster  easier  and  less  painful,  while  the  removal  of  the 
hair  from  the  scrotum  permits  the  applications  that  we 
are  to  order  to  penetrate  more  readily  and  thus  to  act  more 


174       GONORRHEA  AND  ITS  COMPLICATIONS 

efficiently.  The  relief,  which  the  patient  experiences  on 
the  testicles  being  raised,  is  remarkable.  Not  only  the  sense 
of  ' '  sickness ' '  and  f aintness  disappears,  but  every  sensation 
of  pain  is  usually  gone  also.  To  prevent  the  scrotum  and 
perineum  from  sticking  to  the  upper  edge  of  the  adhesive 
plaster,  that  portion  of  the  plaster  which  comes  in  contact 
with  the  scrotum  has  to  be  folded  over  with  another  piece  of 
adhesive  plaster,  or  a  gauze  pad  may  rest  under  the  scrotum. 

Instead  of  the  adhesive  plaster  we  may  use  as  a  make- 
shift a  cigar  box  wrapped  in  several  thicknesses  of  flannel 
or  toweling.  This  is  put  between  the  patient's  thighs  and 
the  scrotum  rests  on  it. 

Having  raised  the  testicles,  the  question  arises,  what  ap- 
plication are  we  going  to  use,  hot  or  cold  ?  It  is  quite  true 
that  the  cold  application,  and  even  an  ice  bag,  very  fre- 
quently gives  the  quickest  relief.  Nevertheless  I  am  not  in 
favor  of  them,  because  I  cannot  get  rid  of  the  impression 
that  induration,  with  its  subsequent  sterility,  is  more  com- 
mon in  cases  in  which  ice  cold  applications  have  been  used. 
I  therefore  prefer  frequently  changed  hot  applications. 
]\Iy  preference  is  for  large  gauze  compresses  wrung  out  of 
a  hot  solution  of  aluminum  acetate  containing  some 
glycerin : 

R  Liquoris  alumini  acetatis,   I  __,_... 

^       ^  I, aa  5V111* 

Glycerim,   J 

Aquae,    Oj. 

M.  ft.  mistura. 

The  compress  is  to  be  covered  with  oil  silk  and,  if  the 
patient  must  be  up  and  about,  the  whole  put  into  a  well 


EPIDIDYMITIS  175 

fitting  suspensory  bandage.  The  compress  should  be  wrung 
out  of  the  hot  solution  every  hour. 

These  applications  have  a  decided  effect  in  reducing  the 
swelling  and  moderating  the  pain,  and  if  continued  for  sev- 
eral days  have,  in  my  opinion,  a  decided  effect  in  preventing 
any  permanent  induration  in  the  epididymis. 

The  application  of  compresses  is  very  troublesome,  as  it 
requires  a  special  nurse,  and  we  therefore  must  sometimes 
get  along  altogether  without  them,  or  after  using  them  for 
twelve  to  twenty-four  hours  we  change  off  to  ointments.  A 
good  ointment  properly  applied  is  also  very  beneficial.  My 
favorite  formula  is : 

I^  Unguenti  hydrargyri, 5ii , 

Guaiacolis, 


Ichthyolis,  ' ^^^^"^ 

Unguenti  belladonnae,  o^s ; 

Adipis  benzoati,  q.  s.  ad gii. 

M.  Sig. :  Apply  externally  twice  or  three  times  a  day. 

Very  delicate  patients  are  sometimes  hypersensitive  to 
guaiacol.  I  have  seen  it  bring  on  a  condition  very  near 
collapse.  Where  the  patient  is  very  young  and  delicate,  I 
therefore  frequently  replace  the  guaiacol  with  methyl 
salicylate. 

Again,  there  are  cases,  where  the  foregoing  ointment 
cannot  be  prescribed  for  an  apparently  trivial,  but  to  the 
patient  all  important  reason :  it  soils  the  underwear  and  the 
bed  linen.  In  such  cases  the  following  ointment  will  be 
found  very  useful : 


176       GONORRHEA  AND  ITS  COMPLICATIONS 

^   Hydrargyri  ammoniati,   5ss ; 

Methylis  salicylatis, 5 j  ; 

Morphinse  sulpliatis,  ^s.  iv ; 

Atropinge  sulpliatis,   gr.  j  ; 

Adipis  lan^e,   §ss ; 

Adipis  benzoati,  oj- 

M.  ft.  ung.  S.     Apply  externally  three  times  a  day. 

The  diseased  testicle,  with  its  epididymis,  is  drawn  down 
so  that  the  scrotum  is  tense  over  it ;  the  ointment  is  gently 
but  thoroughly  rubbed  in;  some  is  then  spread  thickly  on 
a  layer  of  cotton,  in  which  the  testicle  is  enveloped,  some 
oiled  silk  is  put  over  it,  and  the  whole  is  kept  in  place  by 
a  few  turns  of  a  gauze  bandage,  or  a  well  fitting  suspensory 
bandage  may  be  used.  At  first  this  ointment  is  to  be 
changed  twice  or  three  times  a  day,  but  later  a  good  applica- 
tion of  it  once  in  twenty-four  hours  is  sufficient. 

One  other  useful  method  of  dealing  with  the  testicle  may 
be  mentioned.  That  is  the  injection  of  colloidal  silver  (col- 
largol  or  electrargol,  the  latter  being  preferred  by  Hamonic 
and  Asch,  as  being  in  a  finer  state  of  subdivision)  directly 
into  the  epididymis.  I  have  tried  it  in  a  few  cases  and  the 
results  seemed  favorable.  No  anesthetic  is  necessary,  but 
one  of  my  patients  fell  in  a  dead  faint,  from  which  it  took 
him  two  or  three  minutes  to  come  out.  The  skin  over  the 
epididymis  is  made  tense,  painted  with  iodine,  and  the 
sharp  fine  needle  is  plunged  directly  into  the  globus  major 
or  minor,  whichever  happens  to  be  the  most  affected  part. 
My  usual  treatment  has  proved  so  uniformly  successful  in 
my  hands,  however,  that  I  have  recourse  to  this  procedure  in 
only  exceptional  cases. 


EPIDIDYMITIS  177 

Internally  I  order  fifteen  grains  of  sodium  salicylate  four 
times  a  day,  or  eight  grains  of  acetyl-salicylic  acid  three 
times  a  day.  The  value  of  salicylic  preparations  in  epi- 
didymitis LS  beyond  question.  They  not  only  reduce  the 
fever  and  the  local  pain,  but  also  induce  a  condition  of 
euphoria.  "Where  the  fever  is  very  high,  aspirin  may  be 
combined  with  phenacetin  or  antipyrin.  Morphine  should 
be  guarded  against  and  should  be  used  in  very  rare  and 
extreme  cases  only,  for  not  only  does  it  keep  up  the  fever 
and  lock  the  secretions  but  it  induces  constipation,  a  condi- 
tion against  which  we  must  guard  particularly  in  epi- 
didymitis, because  constipation  has  a  decidedly  bad  effect  on 
this  complication,  and  if  prostatitis  happens  to  be  coexistent, 
it  also  aggravates  that.  It  is  therefore  my  practice  always 
to  order  some  magnesium  sulphate  in  all  cases  of  epi- 
didymitis. It  seems  to  me  to  exert  more  than  a  laxative 
effect,  it  aids  in  reducing  the  inflammation. 

A  hot  enema  is  not  only  good  for  any  existing  constipa- 
tion to  clear  out  the  rectum,  but  it  does  the  local  condition 
good,  that  is,  it  improves  any  existing  prostatitis  and 
posterior  urethritis,  and  incidentally  also  the  epididymitis. 
So  that  a  small  but  hot  enema  at  night,  containing  perhaps 
fifteen  grains  of  antipyrin  and  five  minims  of  tincture  of 
opium,  is  a  good  thing. 

Where  the  patient  is  extremely  restless  and  cannot  fall 
asleep,  chloral  or  veronal  should  be  given.  If  morphine  is 
ever  decided  upon,  it  should  be  given  in  the  form  of  rectal 
suppositories,  and  as  a  rule  %  to  %  grain  of  morphine  will 
be  required  to  produce  the  desired  effect. 


178       GONORRHEA  AND  ITS  COMPLICATIONS 

SHOULD    THE   URETHRA   BE   TREATED? 

We  come  now  to  the  question  of  the  treatment  of  the 
urethra.  Should  the  urethra  be  treated  during  an  attack 
of  epididymitis  ?  Locally,  absolutely  no,  under  any  circum- 
stances. This  was  a  universally  accepted  dictum  for  many 
years,  but  recently  some  ultra-active  urologists  have  thought 
that  they  didn't  see  any  reason  why  the  urethra  should  not 
be  treated,  if  the  injections,  irrigations,  etc.,  are  only  given 
gently  and  carefully.  Let  those  urologists  settle  the  matter 
with  their  own  consciences.  I  repeat  that  under  no  circum- 
stances whatever  should  the  urethra  be  treated  locally  dur- 
ing an  attack  of  epididymitis.  There  is  no  injection  or 
irrigation  so  gentle  that  it  may  not  aggravate  matters,  cause 
a  relapse,  or  turn  the  declining  stage  of  the  epididymitis 
into  a  furiously  acute  stage.  To  treat  the  urethra  with  any 
injection,  irrigation,  or  instrument  during  an  acute  epi- 
didymitis is  criminal  folly,  but  internally  we  may  keep  on 
giving  the  same  medicines,  demulcents,  hexamethylena- 
mine,  sandalwood  oil,  or  preparations  containing  it,  etc., 
though  even  these  are  best  given  in  smaller  doses  than  when 
no  epididymitis  is  present. 

Where  the  patient  cannot  go  to  bed,  then  we  start  at  once 
with  the  application  of  the  ointment  above  described ;  oint- 
ment, big  layer  of  nonabsorbent  cotton,  oiled  silk,  the  whole 
supported  by  a  well  fitting  suspensory  or  jockstrap.  A 
home-made  T  bandage  from  a  waistband  and  a  towel,  while 
not  elegant,  answers  the  purpose  and  is  much  cheaper,  which 
to  the  poor  is  an  item.  As  it  is,  gonorrhea  is  a  very  ex- 
pensive luxury,  which  only  the  rich  and  very  well-to-do 
may  permit  themselves. 


EPIDIDYMITIS  179 


STRAPPING   THE   TESTICLE 


Strapping  the  testicle  is  a  very  beneficial  measure.  It 
not  only  relieves  the  pain,  but  it  helps  in  the  absorption  of 
the  inflammatory  exudate,  and  if  properly  applied  the  swell- 
ing diminishes  rapidly  under  its  influence.  In  six  to  eight 
hours  the  diminution  in  the  size  of  the  swollen  epididymis 
may  be  so  great  as  to  be  clearly  apparent.  The  strapping 
with  overlapping  strips  of  adhesive  plaster,  as  originally 
introduced  by  Friecke,  was  very  popular  for  a  long  time, 
and  if  properly  applied  it  did  its  work  well;  but  it  was 
troublesome,  its  removal  every  day  (because  the  testicle 
having  diminished  in  size  it  was  no  longer  useful)  caused 
the  patient  a  great  deal  of  pain,  and  if  applied  improperly, 
it  was  apt  to  do  more  harm  than  good.  It  is,  therefore,  now 
used  by  very  few  genitourinary  surgeons.  In  this  country, 
at  least,  it  has  been  to  a*  great  extent  superseded  by  the 
rubber  bandage  suggested  by  Chetwood.  A  piece  of  light 
rubber  bandage,  about  two  inches  wide  and  three  to  four 
inches  long,  is  taken,  and  a  small  piece  of  adhesive  plaster, 
one  half  an  inch  wide  and  two  inches  long,  is  attached  to 
one  of  its  ends.  The  diseased  testicle  is  pushed  down  to 
the  scrotum  until  the  skin  is  made  as  tense  as  possible  over 
it ;  the  rubber  bandage  is  wrapped  around  the  testicle,  and 
is  held  in  place  by  the  strip  of  adhesive  plaster.  It  may 
be  changed  daily,  which  is  easily  done ;  it  is  simply  a  matter 
of  a  minute.  Care  must  be  taken,  however,  that  the  strip 
of  adhesive  plaster  is  attached  above  the  largest  circumfer- 
ence of  the  testicle.  If  it  is  attached  under  it,  the  testicle 
will  naturally  slip  out  and  up. 

The  epididymis  may  swell  to  the  size  of  a  fist  or  even 


180       GONORRHEA  AND  ITS  COMPLICATIONS 

larger,  in  fact  the  size  in  exceptional  cases  is  hardly  be- 
lievable. While  on  superficial  examination  it  seems  that  it 
is  the  testicle  that  is  swollen,  still  by  careful  manipulation, 
when  the  scrotum  is  raised  and  the  patient  is  in  bed,  we  can 
find  that  the  testicle  is  intact,  of  the  normal  size,  and  merely 
semi-surrounded  by  the  enlarged  and  inflamed  epididymis. 
Occasionally,  however,  there  is  an  effusion  of  fluid  into  the 
tunica  vaginalis,  and  the  testicle  itself  may  participate  in 
the  inflammation.  We  then  have  to  deal  not  with  an  epi- 
didymitis but  with  an  orchiepididymitis  or  epididymoor- 
chitis. 

SEQUELS   OP   EPIDIDYMITIS 

The  induration  of  the  epididymis  and  the  occlusion  of 
the  lumen  of  the  vas  deferens  have  for  their  result,  as  stated 
before,  sterility  of  the  male.  They  either  permit  absolutely 
no  spermatozoa  to  pass,  the  condition  being  one  of  aspermia, 
as  much  so  as  if  the  patient  had  been  castrated;  or  the 
spermatozoa  that  pass  are  very  few  in  number  and  deformed, 
and  do  not  possess  enough  vitality  to  impregnate  the  ovum. 
But,  strange  as  it  may  seem,  this  sterility  is  not  accompanied 
by  any  impotence  or  diminished  libido.  The  latter  may 
even  be  increased.  Nor  does  the  patient's  general  health 
seem  to  be  in  any  way  influenced  for  the  worse.  I  say  this 
is  a  strange  phenomenon,  because  we  know  of  no  other  gland 
in  the  human  organism  whose  excretory  duct  can  be  com- 
pletely obliterated  without  any  damage  to  the  system.  We 
can  only  assume  that  in  some  manner  some  of  the  products 
of  the  testicular  function  are  absorbed  into  the  general  cir- 
culation, even  though  the  ducts  which  give  exit  to  the 
spermatozoa  are  obliterated. 


EPIDIDYMITIS  181 

Beside  the  induration  of  the  epididymis,  with  the  con- 
sequent sterility,  to  which  epididymitis  is  apt  to  give  rise, 
its  only  other  sequel  is  a  neuralgic  pain  in  the  testicles, 
which  may  be  ver^^  difficult  to  get  rid  of.  This  pain  is  apt 
to  make  itself  particularly  noticeable  in  run  down  sexual 
neurasthenics. 

A  tendency  to  tuberculosis  of  the  testicle  is  also  mentioned 
as  one  of  the  sequels  of  epididymitis.  Personally  I  have 
not  noticed  any  such  tendency,  although  a  priori  it  is  not 
difficult  to  understand  that  in  a  patient  predisposed  to  tuber- 
culosis, tuberculosis  of  the  epididymis  and  the  testicle  may 
develop  after  those  organs  have  been  subjected  to  a  severe 
inflammation. 

OPEEATIVE   TREATMENT   OF   EPIDIDYMITIS 

Of  late  years  considerable  has  been  written  concerning  the 
treatment  of  epididymitis  by  puncture  and  epididymotomy. 
I  am  not  enthusiastic  about  the  operative  treatment  of  epi- 
didymitis. It  will  always  remain  almost  exclusively  a  hos- 
pital procedure.  It  requires  general  anesthesia  and  the 
patient  must  stay  in  bed  a  w^ek  or  two — so  where  is  the 
gain '?  Suppose  the  patient  does  recover  a  few  days  earlier 
than  he  does  by  nonoperative  treatment;  the  dangers  of 
general  anesthesia,  the  postoperative  vomiting,  the  fear  of 
the  operation,  are  not  worth  the  difference.  And,  besides, 
I  do  not  believe  in  operating  in  any  condition  where 
we  can  get  along  without  an  operation,  and  I  have 
not  seen  a  single  case  of  epididymitis  which  needed  an 
operation.  If  properly  treated  from  the  start  the  patient 
is  well  in  a  week  or  two,  and  only  in  rare  cases  in  three 
weeks,  and  without  the  shock  and  the  expense  of  an  opera- 


182       GONORRHEA  AND  ITS  COMPLICATIONS 

« 

tion.  I  repeat,  therefore,  that  epididymotomy  will  most 
probably  always  remain  a  hospital  operation — particularly 
recommended  for  soldiers  and  sailors,  whose  time  is  so  ' '  val- 
uable'^  to  the  country.  It  will  not  become  the  method  of 
choice  in  general  practice. 

CASE  REPORT 

The  following  two  cases  present  some  points  of  in- 
terest. A  and  B  are  brothers.  A  was  a  '' rounder,"  had 
several  attacks,  and  with  practically  every  attack  he  de- 
veloped an  epididymitis ;  sometimes  on  the  right  side,  some- 
times on  the  other  and  sometimes  on  both.  He  had  some 
attacks  of  epididymitis  without  an  accompanying  gonorrhea. 
In  five  years  he  had  nine  attacks  of  epididymitis,  for  the 
last  five  of  which  he  was  under  my  treatment.  He  then 
married,  and  at  the  end  of  eleven  months  his  wife  gave 
birth  to  a  healthy  child.  A  year  later  she  had  another 
baby. 

B,  the  younger  brother,  had  an  attack  of  bilateral  epi- 
didymitis, which  laid  him  up  for  six  weeks.  Three  or  four 
months  later  he  married,  and  though  he  has  been  married 
for  three  years  and  is  very  anxious  to  have  a  child,  his  wife 
is  still  childless.  She  has  been  examined  and  nothing  seems 
to  be  wrong  on  her  part,  but  no  spermatozoa  can  be  found 
in  B's  semen,  obtained  either  by  stripping  the  seminal 
vesicles  or  in  the  natural  way  in  a  condom. 

These  cases  seem  to  corroborate  the  observation  made  by 
a  number  of  physicians  that  the  patient  who  had  one  attack 
of  bilateral  epididymitis  is  more  apt  to  be  sterile  than  he 
who  had  several. 


CHAPTER  XXVI 
SEMINAL  VESICULITIS 

Seminal  vesiculitis  or  spermatocystitis  is  an  inflammation 
of  the  seminal  vesicles,  either  one  or  both.  It  is  impossible 
to  say  how  frequent  this  complication  of  gonorrhea  is,  be- 
cause if  present  in  a  mild  degree  it  may  give  practically  no 
symptoms,  and  even  if  present  in  a  fairly  severe  degree 
its  subjective  symptoms  are  confounded  with  or  overshad- 
owed by  those  of  the  posterior  urethra  and  the  prostate.  It 
is  only  by  a  careful  rectal  examination  that  we  become  aware 
of  its  presence. 

The  most  common  cause,  and  by  far  the  most  important 
cause,  of  seminal  vesiculitis  is  gonorrhea.  An  important 
predisposing  cause  is  coitus  during  the  acute  or  subacute 
stage  of  gonorrhea. 

The  symptoms,  a^  stated,  may  not  be  distinguishable  from 
those  produced  by  the  onset  of  an  acute  prostatitis.  There 
is  one  symptom,  however,  which  distinguishes  it  from  the 
latter,  that  is  the  ejaculations  may  be  precipitate  and  the 
.semen  may  be  mixed  either  with  blood  (hemaspermia)  or 
with  pus  (pyospermia).  "When  the  onset  is  very  acute  the 
patient  may  feel  nauseated,  may  vomit  and  feel  like  faint- 
ing. 

The  diagnosis  of  a  seminal  vesiculitis  is  made :  (1)  by  rectal 
examination;  (2)  by  examination  of  the  secretion  obtained 
by  expressing  or  "stripping"  the  seminal  vesicles.     The  ex- 

183 


184       GONORRHEA  AND  ITS  COMPLICATIONS 

amination  by  rectum  is  performed  the  same  way  as  the  ex- 
amination for  prostatitis,  only  here  the  patient  must  in- 
variably assume  a  strongly  stooping  position,  bending  his 
body  practically  to  an  angle  of  90  degrees.  The  finger  must 
be  pushed  in  as  deeply  as  possible,  for  the  seminal  vesicles 
lie  above  the  prostate  and  are  directed  outward.  Sometimes 
the  vesicles  are  situated  so  high  that  even  the  most  expert 
finger  cannot  reach  or  feel  them.  Normal  vesicles,  par- 
ticularly when  empty  (soon  after  coitus)  can  hardly  be  per- 
ceived by  the  examining  finger  and  when  felt  give  the  pa- 
tient no  pain,  but  when  inflamed  and  distended  with  secre- 
tion they  may  be  felt  like  two  miniature,  tortuous  "frank- 
furter" sausages  on  each  side  of  the  prostate,  and  pressing 
on  them  causes  the  patient  the  most  exquisite,  the  most 
sickening  pain  imaginable.  Strong  pressure  on  an  inflamed 
seminal  vesicle  is  even  more  apt  to  induce  syncope  in  the 
patient  than  is  the  massaging  of  an  acute  prostate.  There 
is  one  difference  that  I  have  noticed  between  the  sensation 
produced  by  massaging  a  seminal  vesicle  and  a  prostate: 
the  patient  gets  used  to  the  handling  of  the  latter,  but 
never  gets  used  to  the  handling  of  the  former,  he  always  has 
a  sickish  feeling  after  it. 

To  examine  the  vesicular  secretion  properly,  so  as  to  be 
sure  that  it  comes  from  the  vesicles  and  not  the  prostate, 
the  prostate  is  first  massaged  thoroughly,  then  the  patient 
urinates,  the  bladder  is  washed  out  with  a  quart  of  boric 
acid  (2  per  cent.)  or  mercury  oxy cyanide  solution  (1-5000), 
then  the  bladder  is  filled  again  with  warm  boric  acid  solu- 
tion, the  vesicles  are  massaged,  and  the  patient  empties  his 
bladder.     These  washings  contain  the  vesicular  secretion, 


SEMINAL  VESICULITIS  185 

which  is  then  examined  microscopically.  Microscopic  ex- 
amination will  show  numerous  blood  and  pus  cells,  deformed 
spermatozoa,  gonococci,  and  various  other  bacteria. 

The  greatest  gentleness  must  be  used  in  massaging  the 
seminal  vesicles.  They  are  very  tender  organs,  their  walls 
are  thin,  and  serious  damage  may  be  produced  by  handling 
them  roughly.  The  suggestion,  therefore,  to  use  a  prostatic 
instrument  like  '^Feleki's  Finger"  for  massaging  the  ves- 
icles when  the  finger  is  too  short  to  reach  them  must  be  con- 
demned unequivocally.  We  can  never  know  just  what  force 
is  being  applied  when  we  use  a  heavy  steel  instrument  like 
this.  There  is  great  danger  of  rupturing  the  delicate  wall 
of  the  vesicle. 

I  have  already  mentioned  that  in  some  patients  the  vesi- 
cles are  situated  so  high  or  so  out  of  the  way  that  the  most 
expert  finger  cannot  reach  them  and  therefore  cannot  mas- 
sage them,  but  there  are  cases  where  we  can  feel  the  vesicles 
very  well  and  still  by  the  most  persistent  massage  are  un- 
able to  express  any  of  their  secretion.  This  may  be  due 
either  to  the  peculiar  situation  of  the  ejaculatory  ducts  or 
to  their  complete  inflammatory  occlusion.  Massaging  of 
such  vesicles  will  of  course  do  no  good,  and  if  the  symptoms 
which  their  inflammation  produces  are  severe  and  do  not 
yield  to  treatment  they  will  have  to  be  dealt  with  surgically. 
The  surgical  operation  consists  in  draining  the  vesicles 
through  the  vas  deferens,  as  suggested  by  Belfield  of  Chi- 
cago, or  in  vesiculotomy,  as  suggested  by  Fuller  of  New 
York;  but  as  these  are  not  operations  for  the  general  prac- 
titioner we  will  not  use  up  space  in  describing  them  here. 

The  treatment  of  seminal  vesiculitis  is  essentially  the 


186       GONORRHEA  AND  ITS  COIMPLICATIONS 

same  as  that  of  prostatitis :  gentle  massage,  hot  rectal  irriga- 
tions, the  thermophore,  hot  sitz  baths,  and  gonococcal  or 
preferably  mixed  vaccines. 

Vesiculitis  is  the  longest  lasting  of  all  the  complications 
of  gonorrhea.  Annoying  as  prostatitis  is,  a  seminal  ves- 
iculitis is  still  more  so.  It  requires  indeed  an  inexhaustible 
fountain  of  patience  on  the  part  of  both  physician  and 
patient.  Nevertheless  it  must  be  treated,  because  inflamed 
and  purulent  seminal  vesiculitis  form  the  chief  source 
whence  arise  the  various  metastases  of  gonorrhea,  such  as 
gonorrheal  rheumatism,  gonorrheal  myelitis,  gonorrheal  in- 
flammation of  the  serous  membranes,  endocarditis,  and 
gonococcemia. 


CHAPTER  XXVII 

GONORRHEAL  PROCTITIS— GONORRHEA 
OF  THE  RECTUM 

Gonorrhea  of  the  rectum  is  not  an  uncommon  occurrence. 
And  unfortunately  it  is  rather  on  the  increase.  One  sees 
more  cases  of  gonorrhea  of  the  rectum  now  than  one  used 
to  see,  say,  twenty  years  ago.  It  is  much  more  common  in 
women  than  in  men,  the  infection  being  carried  from  the 
vagina  to  the  anus.  The  infection  is  particularly  easily 
transferred  in  women  who  have  given  birth  to  children  and 
who  have  a  lacerated  perineum. 

The  diagnosis  can  be  readily  made  from  the  history  of 
the  case,  from  finding  gonorrhea  in  the  genital  tract,  from 
the  pain  and  strain  in  the  rectum,  and  from  the  mucopurulent 
and  occasionally  sanguinolent  discharge.  Some  cases  are  so 
mild  that  it  is  difficult  to  differentiate  between  them  and 
simply  catarrhal  proctitis,  but  the  finding  of  the  gonococcus 
in  the  discharge  settles  the  diagnosis. 

As  a  rule  gonorrhea  of  the  rectum  is  readily  amenable  to 
treatment,  and  is  cured  without  leaving  any  sequelae.  In 
some  cases,  however,  severe  erosions  of  the  rectal  mucous 
membrane  are  produced,  which  on  healing  contract  and  give 
rise  to  stricture  of  the  rectum. 

The  treatment  is  simple.  The  rectum  is  examined  by  aid 
of  a  speculum  and  a  strong  light  or  by  the  proctoscope. 
Erosions  are  touched  with  strong  solutions  of  silver  nitrate, 

187 


188       GONOERHEA  AND  ITS  COMPLICATIONS 

and  injections  of  silver  nitrate  or  protargol  into  the  rectum 
are  given  three  or  four  times  a  day.  The  strength  of  the 
silver  nitrate  solution  may  be  from  1-1000  to  1-500,  of  the 
protargol  solution  1-200  to  1-100.  From  4  to  8  oz.  is  used 
per  injection,  and  each  injection  is  held  in  ten  minutes. 
Besides  the  injections  I  prescribe  protargol  suppositories, 
each  suppository  containing  1  to  2  grs.  of  protargol. 
These  may  be  used  twice  or  three  times  a  day. 

^  Protargol  gr.  i 

01.  Theobromatis  gr.  xx 

Mf.  Suppos.  No.  1.     Tal.  Dos.  No.  xxx 

Sig.  one  t.  i.  d. 

^  Argyrol  gr.  v 

01.  Theobromatis  gr.  xxv 

Mf.  Suppos.  No.  1.     Tal.  Dos.  No.  xxx 

Sig.  one  t.  i.  d. 

Constipation  and  straining  at  stool  must  of  course  be  care- 
fully guarded  against.  Before  giving  the  injections  a  plain 
injection  of  water  or  saline  solution  is  given,  so  as  to  make 
sure  that  the  rectal  mucous  membrane  is  clean  and  free  from 
fecal  matter.  The  itching  around  the  anus  is  sometimes 
very  severe  in  gonorrheal  proctitis,  but  this  is  readily 
remedied  by  frequent  washing  of  the  anus  with  hot  water 
and  subsequent  painting  with  a  10  per  cent,  solution  of 
silver  nitrate. 


CHAPTER  XXVIII 

GONORRHEAL  STOMATITIS— GONORRHEA 
OF  THE  MOUTH 

The  existence  of  genuine  cases  of  gonorrheal  infection  of 
the  mouth  is  no  longer  a  subject  of  discussion.  Taking  in 
consideration  the  fact  that  the  mouth  is  lined  with  the  same 
variety  of  epithelium  as  is  the  urethra,  and  taking  in  con- 
sideration the  further  fact  that  certain  sexual  perversions 
are  quite  common,  the  surprise  is  not  that  gonorrheal  in- 
fection of  the  mouth  exists  but  that  the  cases  are  relatively 
so  few  in  number. 

On  the  whole,  the  buccal  mucous  membrane  is  very  re- 
sistant to  the  gonococcus.  In  his  entire  practice  the  writer 
has  had  but  three  cases  of  gonorrheal  stomatitis  where  there 
could  be  no  question  as  to  the  diagnosis — two  in  women  and 
one  in  a  man. 

The  cause  of  the  infection  is  a  purely  local  one,  that  is,  it 
is  due  to  the  direct  transference  of  the  gonococcus  into  the 
mouth.  I  do  not  share  the  view  that  there  is  such  a  thing 
as  a  systemic  gonorrheal  stomatitis,  that  is  a  stomatitis 
caused  by  the  gonococcus  or  its  toxins  affecting  the  mouth 
through  the  blood.  The  method  of  infection  in  adults  is 
due  to  pervert  practices,  or  it  may  perhaps  in  some  cases  be 
due  to  transferring  the  gonococcal  pus  with  the  fingers.  In 
the  newborn  it  is  due  to  infection  from  the  mother  as  the 
child  passes  through  the  vaginal  canal. 

189 


190      GONORRHEA  AND  ITS  COMPLICATIONS 

The  symptoms  of  gonorrheal  stomatitis  are :  a  raw  feeling 
in  the  mouth  with  an  extremely  nasty  taste ;  the  tongue  may 
become  considerably  swollen;  the  mouth  may  be  hard  to 
open ;  the  gums  may  swell,  though  not  necessarily  so.  The 
expectoration  is  thick,  ropy,  occasionally  bloody ;  sometimes 
it  is  slight  in  amount,  in  other  cases  it  may  be  very  abundant. 
In  some  cases  swallowing  is  very  painful,  and  in  some  cases 
impossible.  The  sub-lingual,  parotid  and  lymphatic 
glands  usually  swell;  there  is  no  record,  however,  of  these 
glands  going  on  to  suppuration. 

Properly  treated  this  horribly  nasty  infection  is  cured  in 
one  to  three  weeks.  The  treatment  is  simple :  touching  with 
the  silver  nitrate  stick  or  with  a  saturated  solution  of  silver 
nitrate  any  eroded  spots,  and  using  a  solution  of  silver 
nitrate  1-5000  as  a  gargle,  which  is  to  be  repeated  every 
hour.  Instead  of  silver  nitrate  we  may  use  1-1000  protargol 
solution  as  a  gargle.  The  solution  of  either  the  nitrate  of 
silver  or  the  protargol  should  be  kept  from  three  to  five 
minutes  each  time  in  the  mouth,  and  the  gargling  should 
be  done  thoroughly,  so  as  to  reach  the  fauces.  Where 
gargling  is  difficult  the  solution  of  silver  nitrate  1-1000  or 
protargol  1-200,  or  argyrol  5  per  cent.,  should  be  used  on  a 
cotton  swab,  the  throat,  tongue,  gums,  inside  of  cheeks,  etc., 
being  thoroughly  swabbed  four  or  five  times  a  day. 

Gonorrhea  of  the  Nose.  It  is  questionable  whether 
gonorrhea  of  the  nose  exists.  Certainly  not  a  single  au- 
thenticated case  has  been  reported.  The  subject  may  there- 
fore be  dismissed  with  this  brief  paragraph. 


CHAPTER  XXIX 
STRICTURE 

Stricture  is  a  narrowing  or  constriction  of  the  caliber  of 
the  urethral  canal  at  some  point  or  points.  As  the  urethra 
is  ordinarily  a  closed  canal,  dilating  only  for  the  passage 
of  urine,  semen  and  instruments,  it  would  be  more  correct 
to  define  stricture  as  a  loss  of  or  diminished  dilatability  of 
the  canal. 

Strictures  are  generally  divided  into  spasmodic,  inflam- 
matory and  organic.  It  is  only  to  the  latter  kind  that  the 
name  stricture  should  be  applied.  ^  A  spasmodic  stricture  is 
really  but  a  spasm  of  the  compressor  urethrae  muscle,  and 
should  be  referred  to  as  a  spasm  of  the  muscle  or  spasmodic 
constriction.  Inflammation  itself  rarely  if  ever  produces  a 
definite  constriction  of  the  urethral  lumen,  definite  enough 
for  instance  to  cause  retention  of  urine.  An  inflammation 
superadded  to  a  previous  organic  stricture  may  cause  com- 
plete retention,  but  then  it  is  wrong  to  refer  to  it  as  an 
inflammatory  stricture.  It  is  merely  an  organic  stricture 
which  has  become  inflamed.  The  entirely  different  methods 
of  treatment  in  spasmodic  and  organic  strictures  will  show 
that  spasmodic  stricture  does  not  deserve  the  name  of  stric- 
ture. As  spasmodic  stricture  is  of  little  importance  path- 
ologically, I  will  devote  but  little  space  to  it,  paying  special 
attention  to  organic  stricture,  and  particularly  to  organic 

stricture  of  gonorrheal  origin. 

191 


192       GONORRHEA  AND  ITS  COMPLICATIONS 

Strictures  are  not  met  with  nowadays  with  the  same  fre- 
quency that  they  used  to  be  in  former  days.  This  is  both 
because  there  is  less  neglect  on  the  part  of  patients  in  treat- 
ing themselves  for  gonorrheal  affections,  and  because  our 
treatment  is  more  rational  and  more  scientific  than  it  used 
to  be.  But  even  so  they  occur  with  greater  frequency  than 
they  should,  and  a  stricture  occurring  in  a  patient  who  has 
been  under  a  physician's  treatment  right  along  is  a  direct 
reproach  to  the  physician.  It  shows  that  the  treatment  was 
either  insufficient  or  incorrect,  for  while  we  cannot  prevent 
epididymitis  in  every  one  of  our  gonorrheal  patients,  while 
we  cannot  prevent  prostatitis  in  every  one  of  our  cases, 
stricture  can  be  and  should  be  prevented  in  every  case. 
We  cannot  prevent  the  migration  of  the  gonococci  into 
various  glands  and  neighboring  organs,  once  they  invaded 
the  submucous  tissue  of  the  urethral  canal,  but  we  can  pre- 
vent connective  tissue  formation  in  every  instance. 

Organic  stricture  is  a  narrowing  of  the  urethra  formed 
by  bands  of  connective  tissue  in  the  mucous  and  submucous 
layers  of  the  canal.  It  may  be  due  to  trauma  (wound, 
injury),  and  such  strictures  are  called  traumatic,  or  to 
inflammation  of  the  urethra.  Of  these  inflammations  the 
most  common  one  is  gonorrhea.  While  a  stricture  may  be 
produced  by  a  non-gonorrheal  urethritis,  still  it  is  so  rare 
as  to  be  practically  negligible.  In  fact  all  possible  causes 
of  stricture  pale  into  insignificance  as  compared  with  the 
one  great  cause,  namely  gonorrhea,  which  is  the  etiologic 
factor  in  about  80  or  85  per  cent,  of  all  strictures. 

A  stricture  that  permits  the  passage  of  a  22  French 
bougie  or  sound  is  referred  to  as  stricture  of  wide  caliber. 
Those  that  are  so  narrow  that  they  will  not  permit  the 


STRICTURE  193 

passing  of  a  22  or  20  French  sound  are  spoken  of  as  stric- 
tures of  a  narrow  caliber.  A  stricture  that  will  permit  the 
passage  of  only  a  filiform  bougie  is  spoken  of  as  filiform 
stricture.  A  stricture  that  does  not  permit  the  passage  even 
of  a  filiform  is  spoken  of  as  an  impermeable  stricture,  and 
causes  complete  retention  of  urine.  Strictures  which  are 
dilatable  by  sounds  but  immediately  return  to  their  former 
caliber  are  referred  to  as  resilient  strictures. 

Strictures  may  be  single,  but  this  is  rarely  the  case  ex- 
cept when  they  are  of  traumatic  origin.  When  of  gonor- 
rheal origin  they  are  generally  multiple.  We  generally 
find  two  or  three  strictures  in  the  same  urethra;  in  excep- 
tional cases  we  may  find  as  many  a^  15  or  20.  Narrow 
strictures  (imagine  a  thread  tied  around  the  urethra)  are 
spoken  of  as  linear;  broader  strictures  (imagine  a  tape  tied 
around  the  urethra)  are  referred  to  as  annular,  ring-like. 
Multiple  strictures,  or  broad  annular  strictures  in  which 
the  lumen  instead  of  being  in  the  center  is  in  the  side  of  the 
constriction  and  in  which  the  entire  passage  becomes  tor- 
tuous, are  spoken  of  as  tortuous  strictures.  Strictures  with 
which  the  general  practitioner  has  to  deal  are  fortunately 
most  commonly  in  the  anterior  urethra.  Traumatic  stric- 
tures are  generally  situated  in  the  membranous  urethra^ 
There  are  no  strictures,  or  so  seldom  as  to  be  entirely  neg- 
ligible, in  the  prostatic  urethra. 

SYMPTOMS 

A  stricture  of  wide  caliber,  or  even  of  a  somewhat  narrow 
caliber,  may  present  no  symptoms  that  the  patient  is  aware 
of.  A  patient  may  have  a  stricture  for  ten  or  more  years 
without  knowing  it,  or  without  paying  any  attention  to  it, 


194       GONORRHEA  AND  ITS  COMPLICATIONS 

when  suddenly,  after  a  debauch,  or  sexual  excess,  or  a  cold, 
he  is  taken  with  complete  retention  of  urine,  when  he  ap- 
plies to  the  physician,  who  then  discovers  a  stricture  of 
apparently  many  years  ^  standing. 

But  as  a  rule  strictures  do  give  symptoms.  One  of  the 
commonest  ones  is  the  well  known  gleet,  which  consists  of 
a  slight  urethral  discharge.  The  discharge  is  generally 
supposed  to  be  most  common  in  the  morning,  but  this  is 
only  so  because  during  the  night  the  patient  passes  the 
longest  time  without  urinating,  and  the  discharge  has  time 
to  accumulate  in  sufficient  amount  to  be  noticed.  But  if 
the  patient  should  abstain  from  urinating  during  the  day 
for  eight  or  nine  hours  we  will  be  sure  to  find  the  discharge 
then  too.  In  fact  I  have  had  a  number  of  cases  in  whom 
the  discharge  in  the  morning  was  extremely  scanty,  so  as 
to  be  noticed  or  squeezed  out  only  with  difficulty,  while 
towards  evening  after  their  day's  work  it  was  much  more 
abundant.  This  was  also  true  of  shreds  in  the  urine. 
While  as  a  rule  the  shreds  are  much  more  numerous  in  the 
morning,  this  is  only  because  of  the  longer  time  passed  with- 
out urinating.  And  just  as  the  discharge  may  be  more 
abundant  in  the  evening,  so  the  morning  urine  may  be  prac- 
tically free  from  shreds  while  the  evening  urine,  if  the  pa- 
tient abstained  from  urinating  for  several  hours,  may  be  full 
of  them.  While  a  gleet  may  occur  without  a  stricture,  still 
stricture  is  its  most  common  cause,  and  in  every  case  of 
obstinate  gleet,  refusing  to  heal  under  ordinary  injections, 
we  should  suspect  stricture;  and  on  examination  we  will 
in  the  vast  majority  of  cases  find  it. 

The  next  symptom  is  a  change  in  the  size  and  character 
of  the  urinary  stream.     It  is  this  that  often  brings  the 


STRICTURE  195 

patient  to  the  doctor.  Besides  being  smaller  in  size  than 
usual,  it  may  assume  a  fantastic  direction,  going  either  to 
one  side  or  downward,  or  may  become  corkscrew  shaped; 
or,  which  is  very  common,  it  splits  in  two  or  three  different 
directions. 

Then  there  is  almost  invariably  dribbling  of  the  urine. 
The  final  contraction  of  the  vesico-urethral  musculature  is 
insufficient  to  drive  out  the  last  drops  of  the  urine  on 
account  of  the  obstruction  met  on  the  way,  and  they  there- 
fore dribble  away  by  the  action  of  gravity.  Very  often 
they  do  not  dribble  away  entirely  but  remain,  some  in  front, 
some  in  back  of  the  stricture,  keeping  up  a  low  grade  of 
inflammation.  Having  to  overcome  an  obstacle  during  each 
act  of  urination,  the  musculature  of  the  neck  of  the  bladder 
becomes  hypertrophied,  and  as  is  the  case  with  all  unnat- 
urally hypertrophied  muscle,  it  becomes  weakened.  There 
is  developed  a  low-grade  inflammation  of  the  neck  of  the 
bladder  with  some  cystitis,  and  this  increases  the  frequency 
of  micturition,  which  is  another  important  symptom  of 
long-standing  stricture.  The  patient  may  have  to  urinate 
every  hour  or  every  half  hour  during  the  day  and  several 
times  during  the  night.  The  pain  is  sometimes  slight  but 
may  become  excruciating,  so  that  the  patient  will  double  up 
during  the  act  of  micturition. 

In  long  neglected  stricture  there  may  be  hypertrophy  of 
the  bladder  walls,  well  developed  cystitis,  pyelonephrosis, 
pyelitis,  etc.,  but  these  are  remote  effects  of  stricture,  and 
we  are  here  concerned  only  with  gonorrhea  and  its  imme- 
diate complications. 

And  finally  we  may  have  complete  retention  with  ex- 
travasation or  infiltration  of  the  urine  and  various  fistulge. 


196       GONORRHEA  AND  ITS  COMPLICATIONS 

The  sexual  symptoms  of  stricture  are  important,  because 
they  are  frequent,  annoying,  and  often  overshadow  the 
urinary  symptoms  caused  by  the  stricture.  These  symp- 
toms are  weakened  or  imperfect  erections,  premature  ejac- 
ulation, diminished  voluptas  during  the  act,  a  feeling  of 
scalding  or  burning  in  the  urethral  canal  during  and  after 
the  ejaculation  of  the  semen,  and  occasionally  a  disturbance 
in  ejaculation.  The  semen  may  fail  to  discharge  externally 
at  all,  running  back  into  the  bladder,  or  it  oozes  out  slowly 
after  the  erection  has  subsided.  As  a  rule  there  is  a  dimin- 
ished desire  for  intercourse  but  occasionally,  as  so  often 
happens  in  the  inflammations  around  the  posterior  urethra 
and  the  prostate,  there  may  be  just  enough  inflammation  to 
keep  up  an  irritation  which  makes  the  patient  believe  that 
he  is  constantly  erotically  excited;  it  is  a  fictitious  libido. 
In  irritable  stricture  pollutions  are  also  frequent,  and  it  is 
quite  frequently  here  that  we  have  to  deal  with  retro- 
pollutions  or  ejaculation  of  the  semen  into  the  bladder. 

TREATMENT 

The  treatment  of  stricture  is  mechanical  and  operative. 
The  general  practitioner  will  seldom  have  to  have  recourse 
to  the  operative  method,  as  we  can  accomplish  as  good  re- 
sults with  the  vast  majority  of  strictures  by  mechanical 
dilating. 

Dilatation  is  performed  by  means  of  silk  woven  bougies, 
steel  sounds,  and  the  various  several-branched  dilators. 
For  strictures  which  will  not  admit  any  more  than  12  or  15 
French  we  use  silk- woven  bougies,  because  a  very  thin  steel 
sound  is  apt  to  make  a  false  passage.  But  for  strictures 
above  15  we  use  steel  sounds  or  dilators. 


STRICTURE  197 

The  greatest  gentleness  must  be  exercised  in  introducing 
a  sound.  Very  much  damage,  aggravation  of  the  inflamma- 
tion, chills,  septic  infection,  false  passages,  severe  hemor- 
rhages, have  been  caused  and  are  being  caused  by  physicians 
with  too  heavy  a  hand  or  too  much  in  a  hurry  to  accom- 
plish results. 

To  introduce  a  sound  properly  wash  the  glans  and  the 
meatus  well  with  a  1-5000  bichloride  solution,  irrigate  the 
portion  anterior  to  the  stricture  with  a  2  per  cent,  boric  acid 
solution,  and  if  you  see  the  patient  for  the  first  time,  or  if 
you  know  that  the  patient  is  of  a  nervous  disposition,  instill 
a  few  drops  of  a  4  per  cent,  alypin  and  a  few  drops  of  a 
1-1000  adrenalin  solution  in  the  neighborhood  of  the  stric- 
ture. This  not  only  takes  away  the  pain  to  a  great  extent, 
but  also  makes  the  lumen  of  the  stricture  larger,  more 
patent,  by  taking  away  the  inflammatory  swelling.  Then 
lubricate  the  bougie,  or  if  it  is  a  sound  pass  it  first  through 
a  flame,  which  sterilizes  and  warms  it  at  the  same  time, 
then  lubricate  it  with  a  sterile  lubricant,  oil  being  the  best, 
and  introduce  it  gently  through  the  stricture.  Do  not  try 
to  force  it  too  much.  Slight  force  is  permissible,  but  not 
enough  force  to  tear  or  divulse  the  stricture.  Sometimes  by 
waiting  with  the  tip  of  the  sound  at  the  opening  of  the 
stricture  for  a  few  moments,  a  stricture  which  seemed  to  be 
absolutely  impermeable  will  become  permeable  and  permit 
the  passing  of  the  sound.  This  is  true  not  only  of  spas- 
modic but  of  genuine  organic  strictures,  because  a  slight 
amount  of  dilatability  most  of  them  possess. 

After  having  introduced  the  sound  let  it  stay  there  for 
flve  to  ten  minutes.  I  believe  that  passing  the  sound  and 
taking  it  right  out  is  insufficient.     It  is  not  only  the  mo- 


198       GONORRHEA  AND  ITS  COMPLICATIONS 

mentary  dilatation  of  the  stricture  that  does  good,  but  the 
more  or  less  prolonged  contact  of  the  stricture  with  the  steel 
sound  that  produces  the  absorption  of  the  scar  tissue. 

Always  be  sure  to  have  the  patient  take  10  grains  of 
hexamethylenamine  about  an  hour  before  he  comes  to  the 
office,  and  10  grains  afterwards.  Many  infections  and 
urethral  chills  are  avoided  thereby. 

The  sounds  may  be  introduced  every  two  or  three  days, 
and  at  each  visit  we  may  use  a  larger  size  sound.  It  will  be 
found  that  very  often  when  we  are  unable  to  pass  a  larger 
sized  sound  we  will  be  able  to  do  so  if  we  pass  before  a 
smaller  sized  sound:  In  other  words,  suppose  we  pass  on 
Monday  a  24  size  sound ;  if  we  try  on  Wednesday  to  pass  a 
25  or  26  size  sound  we  may  not  be  able  to  do  so,  but  if  we 
pass  again  a  24  size  sound,  leave  it  in  for  a  moment,  then 
remove  it  and  try  to  pass  a  25  or  26  size  sound,  the  latter 
will  pass  in  easily.  In  this  way  we  continue  the  passing  of 
the  sounds  until  we  are  able  to-  pass  easily  a  30  or  32. 
Higher  we  need  not  go.  When  we  have  reached  that  size 
we  can  order  the  patient  to  come  every  two  weeks  or  every 
month  for  an  examination  to  observe  if  the  stricture  began 
to  recontract,  and  it  is  also  a  very  good  idea  to  teach  the 
patient  himself  to  pass  the  sound.  If  he  is  intelligent  and 
can  be  taught  to  use  asepsis  and  commonsense,  we  can  trust 
him  to  pass  the  sound  once  a  month  or  once  in  two  months, 
and  in  this  way  there  is  no  danger  of  his  stricture  recontract- 
ing. 

DILATORS 

The  dilators  introduced  by  Kollmann  and  Oberlander 
present  a  great  advantage  over  the  steel  sounds,  for  they 
may  be  passed  through  a  meatus  as  small  as  21,  and  can 


STRICTUKE  199 

be  dilated  when  in  the  urethra  to  any  size  we  wish.  As 
most  of  the  strictures  that  the  general  practitioner  has  to 
deal  with  are  in  the  anterior  urethra,  it  is  the  anterior  or 
straight  dilator  that  he  will  have  to  use  mostly.  The  thin 
rubber  sheath  which  accompanies  the  dilators  is  slipped  on 
the  dilator,  the  dilator  is  stretched  to  its  full  capacity  to 
make  sure  of  the  integrity  of  the  sheath,  it  is  then  closed 
again,  lubricated  with  a  sterile  lubricant,  introduced  into 
the  urethra,  and  dilated  to  the  desired  size.  The  in- 
dicator dial  on  the  dilator  shows  just  the  degree  of  dilata- 
tion, and  with  each  sitting  the  dilator  may  be  dilated  two 
or  three  divisions  higher. 

After  the  removal  of  the  sound  or  the  dilator  it  is  well 
to  instill  a  few  drops  of  a  %  of  1  per  cent.  (1 :500)  solution 
of  tincture  of  iodine  in  the  neighborhood  of  the  stricture, 
which  acts  both  as  an  antiseptic  and  as  a  '^healing"  agent. 

MEATOTOMY 

Some  meati  are  so  small  that  they  won't  even  permit  the 
passage  of  a  dilator.  Such  meati  must  be  cut  before  we  can 
expect  to  do  anything  with  the  stricture.  While  there  are 
numerous  meatotomes  on  the  market  invented  by  surgeons 
anxious  to  be  immortalized  by  giving  their  name  to  an  in- 
strument or  by  enterprising  manufacturers,  they  are  all 
superfluous.  All  that  is  necessary  is  a  blunt-pointed 
bistoury. 

"Wash  the  glans  and  the  meatus  thoroughly  with  a  1-5000 
bichloride  solution.  If  you  are  very  particular,  irrigate  the 
anterior  urethra  for  a  couple  of  inches  or  swab  it  out  with 
a  cotton  swab  dipped  in  the  same  solution,  then  insert  in 
the  meatus  a  bit  of  cotton  dipped  in  a  cocaine  or  alypin- 


200      GONORRHEA  AND  ITS  COMPLICATIONS 

adrenalin  solution.  Or  instead  of  the  cotton  just  a  half 
grain  of  cocaine  powder  or  crystals  may  be  deposited  on  the 
floor  of  the  meatus  and  about  5  drops  of  adrenalin  1-1000 
dropped  in.  After  about  three  minutes  the  floor  of  the 
meatus  will  be  seen  to  have  become  blanched.  You  then  in- 
troduce the  bistoury  and  cut  exactly  in  the  median  line  on 
the  floor  of  the  urethra  as  far  as  you  wish  to  have  it  cut. 
Supporting  the  floor  of  the  meatus  with  one  finger  of  the 
left  hand  will  tell  you  just  exactly  whether  and  how  far  to 


Cauterizing  Tip  for  Meatotomy 


Meatus  Sound  for  Dilating  and  Measuring 
the  Meatus. 

cut.  After  cutting  pass  a  short  anterior  sound  to  make 
sure  that  you  have  cut  sufficiently.  It  is  better  to  cut  a 
little  more  than  a  little  less,  because  there  will  be  some  re- 
contraction  on  healing.  If  cut  exactly  in  the  median 
line  there  will  be  very  little  bleeding.  If  there  is  an  abun- 
dant hemorrhage  compress  the  urethra  laterally  for  several 
minutes,  or  put  a  bandage  around  the  glans,  and  the  hemor- 
rhage will  stop.  Before  sending  the  patient  home  take  a 
piece  of  a  wooden  applicator  or  a  toothpick,  wrap  some  ab- 
sorbent cotton  well  around  it,  dip  it  in  1-1000  adrenalin 
solution,  and  insert  it  in  the  meatus.  The  patient  removes 
it  at  the  next  urination. 

Never  cut  on  the  roof  of  the  urethra,  as  I  have  seen  more 
than  one  physician  do.     It  only  cuts  the  glans  without  act- 


STRICTURE  201 

ually  dividing  the  constriction,  which  is  on  the  floor  of  the 
urethra. 

Some  meati  have  a  tendency  to  reunite  unless  prevented 
from  doing  so,  and  this  is  prevented  by  passing  a  short  steel 
sound  several  times  a  day,  and  by  inserting  between  urina- 
tions a  bit  of  cotton  smeared  with  borated  vaseline. 

When  the  little  operation  of  meatotomy  is  healed  or  about 
healed,  then  we  commence  with  the  introduction  of  sounds 
or  dilators. 

While  the  meatus  should  be  cut  sufficiently  large  to  admit 
24  or  26  French,  I  see  no  reason  for  cutting  it  as  some  do  to 
32  or  34.  There  was  an  excuse  for  doing  it  before  the  intro- 
duction of  dilators.  It  was  necessary  in  order  to  permit  us 
to  pass  a  32  or  34  sound.  But  now  when  we  have  the 
dilators  with  a  caliber  of  21-23  French  it  is  not  necessary 
to  cut  the  meatus  much  more  than  that.  The  excuse  that 
the  physician  does  not  possess  a  KoUmann  dilator  and  has 
only  sounds  is  not  a  valid  one.  He  should  purchase  one. 
The  patient's  urethra  must  not  be  slashed  merely  because 
the  physician  does  not  possess  a  necessary  instrument. 

I  am  opposed  to  excessive  meatotomies  not  on  purely 
sentimental  or  esthetic  grounds,  but  because  in  my  opinion 
they  interfere  with  proper  urination,  and  quite  possibly 
also  with  proper  intercourse.  When  water  issues  from  a 
tube  of  a  narrow  caliber,  but  with  a  wide  opening,  it  will 
splash,  and  people  with  excessively  cut  meati  do  not  pass  a 
uniform  strong  stream  of  urme.  I  have  had  the  impression 
that  excessively  cut  meati  are  also  a  cause  of  premature 
ejaculation.  I  am  therefore  opposed  to  cutting  the  meatus  to 
a  size  larger  than  24  or  26.  With  the  dilators  it  is  unneces- 
sary, and  it  may  be  injurious. 


CHAPTER  XXX 
GONORRHEAL  ARTHRITIS 

Gonorrlieal  arthritis  or  gonorrheal  inflammation  of  the 
joints  is  not  a  very  frequent  complication  of  gonorrhea.  It 
occurs  in  about  2  per  cent,  of  all  gonorrheics  and  is  much 
more  frequent  in  the  male  than  in  the  female  sex,  not  only 
absolutely — for  this  is  self -understood,  so  many  more  men 
have  gonorrhea  than  women — but  also  relatively. 

But  he  whom  it  does  attack  has  the  devil  to  pay.  While 
of  late  the  results  of  our  treatment  have  been  better  than 
they  used  to  be,  nevertheless  there  are  still  cases  which  resist 
every  kind  of  treatment,  and  I  know  personally  several 
cases  of  patients  whose  careers  have  been  ruined  by  this 
complication.  One  is  the  case  of  a  young  pianist,  very 
talented  and  very  promising,  who  had  to  give  up  his  hopes 
and  his  profession  on  account  of  an  ankylosed  wrist  joint, 
due  to  gonorrheal  arthritis.  Another  case  is  that  of  a  fairly 
well  known  surgeon  whose  finger  joints  became  thickened 
and  somewhat  ankylosed,  and  who  had  to  give  up  surgery 
and  fall  back  on  internal  medicine,  where  he  is  much  less 
of  a  success  than  he  would  have  been  in  surgery. 

At  first  no  causal  relationship  was  thought  of  between 
joint  inflammations  and  gonorrhea.  When  a  patient  hav- 
ing gonorrhea  developed  inflammation  of  one  or  more  joints 
it  was  considered  merely  a  coincidence.  Any  man  can  get 
rheumatism,  and  an  inflamed  joint  during  the  course  of  an 
acute  or  chronic  gonorrhea  was  merely  considered  rheu- 

202 


GONORRHEAL  ARTHRITIS  203 

matism,  for  which  the  gonorrhea  was  not  in  any  way  re- 
sponsible. Later  on  when  cases  of  arthritis  in  the  course 
of  gonorrhea  were  seen  to  be  too  frequent  to  be  accounted 
for  merely  by  coincidence  it  was  thought  that  the  gonorrhea 
acted  as  a  predisposing  cause  by  weakening  the  organism, 
reducing  resistance,  etc.  Finally,  however,  gonococci  were 
found  in  the  exudation  around  the  joints,  and  it  was  then 
seen  that  the  gonococcus  plays  not  merely  a  predisposing  but 
a  direct  role. 

It  must  not  be  thought,  however,  that  in  every  case  of 
gonorrheal  arthritis  gonococci  may  be  found.  In  some 
cases  other  bacteria,  such  as  staphylococci  and  streptococci 
are  found ;  in  still  others  no  bacteria  whatever  can  be  found. 
In  such  cases  it  is  assumed  that  the  inflammation  is  caused 
not  by  the  gonococci  themselves  but  by  the  toxins  generated 
by  the  gonococci. 

Nor  must  we  blindly  assume  that  every  inflammation  of 
a  joint  occurring  during  the  course  of  a  gonorrhea  must 
necessarily  be  gonorrheal,  for  a  patient  with  gonorrhea  may, 
the  same  as  any  other  man,  get  an  attack  of  acute  inflam- 
matory^ rheumatism.  This  must  be  borne  in  mind  to  avoid 
regrettable  failures  in  practice. 

While  any  gonorrheal  focus  in  the  genito-urinary  tract 
may  give  rise  to  gonorrheal  arthritis,  it  is  particularly  fre- 
quent in  cases  of  prostatitis  and  seminal  vesiculitis.  The 
latter  is  considered  the  most  important  etiologic  factor  on 
account  of  the  rich  network  of  bloodvessels  which  surround 
the  vesicles. 

Points  of  differential  diagnosis  between  it  and  acute  rheu- 
matism or  rheumatic  arthritis  are :  the  presence  of  a  gonor- 
rhea ;  the  fever  is  much  higher  in  inflammatory  rheumatism 


204       GONORRHEA  AND  ITS  COMPLICATIONS 

than  it  is  in  gonorrheal  arthritis;  also  the  pain  is  more 
severe  and  more  joints  are  affected;  while  in  gonorrheal 
arthritis  two  or  three  joints  may  be  affected,  as  a  rule  only 
one  is  affected. 

The  frequency  of  the  joints  affected  are  as  follows,  in  the 
order  named:  knee  joint,  ankle  joint,  wrist  joint,  finger 
joint,  elbow  joint,  shoulder  joint,  hip  joint  and  jaw.  The 
knee  joint,  as  said,  is  the  most  frequent,  furnishing  as  many 
cases  as  all  the  other  joints  combined. 

The  symptoms  vary  from  slight  transient  pains  in  and 
about  the  joint  without  any  inflammation  to  a  severe  in- 
flammation with  effusion.  The  effusion  may  be  serous  in 
character,  sero-fibrinous  or  purulent.  The  pain  in  the 
effused  joint  may  vary  from  none  at  all  to  one  almost  as 
severe  as  that  of  acute  articular  rheumatism.  The  attack 
may  come  on  suddenly.  There  may  be  a  large  effusion  of 
liquid  around  the  knee  joint,  the  skin  over  the  knee  joint 
may  be  red,  and  still  there  may  be  no  pain  whatever,  either 
spontaneous  or  on  handling  and  pressing. 

The  inflammation  may  end  in  resolution,  in  ankylosis,  or 
in  abscess,  and  unfortunately  there  is  a  tendency  to  recur- 
rence. There  are  some  rare  cases  in  which  not  only  the 
synovial  membranes  of  the  joint  but  also  the  periarticular 
tissues  participate,  the  joint  becoming  a  phlegmonous 
abscess  which  requires  prompt  surgical  treatment.  Such 
cases,  however,  are  rare,  and  the  general  practitioner  will 
not  have  many  chances  to  see  them. 

TREATMENT 

Frankness  demands  that  we  state  at  the  outset  that  the 
treatment  of  gonorrheal  arthritis  can  not  yet  be  termed  a 


GONORRHEAL  ARTHRITIS  205 

brilliant  success.  "We  cure  many  cases,  we  relieve  many- 
more,  but  many  cases  seem  to  resist  all  efforts ;  and  we  are 
unable  to  predict  what  cases  will  be  benefited  and  what  cases 
will  remain  uninfluenced  by  treatment.  Sometimes  the  ap- 
parently mildest  cases  laugh  at  all  our  efforts,  while  severe 
cases  with  joint  involvement,  where  there  is  even  an  appre- 
hension that  operative  measures  may  become  necessary,  get 
along  very  smoothly. 

It  is  perfectly  legitimate  to  start  every  case  of  gonorrheal 
arthritis  on  salicylic  preparations,  both  internally  and  ex- 
ternally. We  have  a  right  to  do  so  for  two  reasons.  First 
of  all,  the  diagnosis  between  gonorrheal  arthritis  and  rheu- 
matism is  not  so  absolute  that  the  possibility  of  error  can 
always  be  excluded.  A  man  with  a  gonorrhea  having  pain 
and  inflammation  in  the  joints  need  not  necessarily  have, 
as  stated  before,  gonorrheal  arthritis.  A  man  with  gonor- 
rhea can  get  ordinary  rheumatism  the  same  as  any  other 
man.  Then  there  may  be  such  a  thing  as  mixed  rheumatism, 
articular  inflammation  due  to  the  gonorrheal  germ  and  its 
toxins  and  to  other  germs.  And  second,  even  in  pure  cases 
of  gonorrheal  arthritis  the  salicylic  preparations  are  of  some 
benefit,  though  of  course  the  benefit  is  slight  as  compared 
with  the  benefit  in  true  rheumatism,.  I  therefore  start  every 
case  of  gonorrheal  rheumatism  with  large  doses  of  sodium 
salicylate  (15  to  60  grs.),  salol  (5  to  10  grs.)  or  aspirin 
(8  to  15  grs).  Externally  I  have  the  painful  parts  rubbed 
in  with  an  ointment  consisting  of  methyl  salicylate,  lard  and 
woolf  at : 

^  Methyl  salicylatis,  3ij  (8.0) 

Adipis 

Adipis  lanae  aa,  3iv  (16.0) 


206       GONORRHEA  AND  ITS  COMPLICATIONS 

This  is  well  rubbed  in,  covered  with  non-absorbent  cotton 
and  oiled  silk  or  rubber  tissue.  The  whole  is  held  in  place 
by  a  well  fitting  gauze  or  rubber  bandage.  This  treatment 
produces  a  beneficial  effect  for  three  reasons:  first,  on  ac- 
count of  the  analgesic  action  of  the  methyl  salicylate ;  second, 
on  account  of  the  partial  immobilization  of  the  joint;  third, 
on  account  of  the  warmth  and  the  partial  passive  hyperemia 
induced  by  the  rubber  tissue  and  bandage. 

Instead  of  the  ointment  I  often  have  the  joints  and  painful 
parts  painted  with  the  following  mixture : 

Acidi  salicylici,  5j  (4.0) 
Menthol,  gr.  xv  (1.0) 
Guaiacol,  gr.  xxx  (2.0) 
Alcohol,  §i  (30.0) 

The  joint  is  painted,  then  protected  with  non-absorbent 
cotton,  oiled  silk  and  rubber  tissue  the  same  as  after  the  use 
of  the  ointment. 

In  some  cases  inunction  with  unguentum  Crede  seems  to 
be  distinctly  beneficial. 

If  the  salicylic  preparations  seem  to  exert  no  effect  we 
may  proceed  to  saturate  the  patient  with  calcium  sulphide 
(calx  sulphurata — sulphurated  lime)  and  arsenic  iodide. 
The  sulphurated  lime  may  be  given  in  doses  of  1  to  2  grains 
three  to  four  times  a  day,  the  arsenic  iodide  in  doses  of 
Koo  to  Yqo  gr.  three  to  four  times  a  day.  Be  sure  to  get  a 
good  quality  of  calcium  sulphide  or  calx  sulphurata,  because 
much  of  it  on  the  market  is  practically  nothing  but  calcium 
sulphate,  which  is  inert. 

Bier's  hyperemia  is  a  well  recognized  procedure  in  the 


GONORRHEAL  ARTHRITIS  207 

treatment  of  gonorrheal  arthritis,  and  in  some  cases  gives 
very  excellent  and  rapid  results.  In  other  cases,  however,  it 
fails  completely. 

Vaccinotherapy.  Gonorrheal  arthritis  is  about  the  one 
complication  of  gonorrhea  in  which  we  are  justified  in  using 
gonorrheal  vaccines.  Not  that  the  results  are  so  brilliant, 
but  they  are  better  than  in  gonorrheal  urethritis  and  in  its 
other  complications ;  and  second,  because  the  disease  is  often 
resistant  to  other  treatment,  and  in  such  cases  we  are  justi- 
fied in  doing  something. 

Fifty  million  gonococci  should  be  injected  as  an  initial 
dose  (in  women  and  young  individuals  we  may  commence 
with  25,000,000),  gradually  increasing  the  dose  to  500,000,- 
000.  The  treatment  is  not  to  be  kept  up  indefinitely  or  for  a 
period  of  several  months,  as  I  have  seen  it  done  in  a  number 
of  cases.  A  physician  with  common  sense  will  very  quickly 
see  whether  the  treatment  is  beneficial,  remains  without 
effect  or  is  injurious.  In  some  cases  the  mixed  gonococcus 
vaccine  seems  to  do  better  than  the  gonococcus  vaccine 
alone. 

And  last  but  not  least  the  gonococcal  foci  must  be  treated 
vigorously.  By  vigorously  I  do  not  mean  roughly  or  stren- 
uously, but  I  mean  gently  and  persistently.  There  is  no  use 
hoping  to  cure  a  patient  of  his  gonorrheal  arthritis  if  there 
is  an  active  or  even  a  mild  gonorrheal  process  in  the  urethra, 
or  if  there  are  gonococci  in  the  prostate  or  in  the  vesicles. 
The  urethra  must  be  irrigated,  the  prostate  and  the  vesicles 
must  be  massaged,  and  everything  else  possible  must  be  done 
to  cure  the  local  lesions  and  to  eliminate  the  gonococci  from 
the  system. 

Some  surgeons  advocate  drainage  of  the  seminal  vesicles 


208       GONORRHEA  AND  ITS  COMPLICATIONS 

or  their  removal  as  a  cure  for  gonorrheal  arthritis.  I  have 
my  opinion  of  vesiculotomy  and  vesiculectomy,  but  as  these 
are  not  operations  which  will  be  undertaken  by  the  general 
practitioner,  for  whom  alone,  we  repeat,  this  book  is  written, 
it  is  not  necessary  to  discuss  them  here. 


CHAPTER  XXXI 

GONORRHEA  vs.  TOBACCO,  ALCOHOL 
AND  SEXUAL  INTERCOURSE 

I  kaow  that  what  I  will  say  here  will  appear  as  rank 
heresy.  But  I  have  so  many  heresies  to  answer  for  that  one 
heresy  more  or  less  does  not  matter.  And  then  heretics 
nowadays  are  not  consigned  to  the  auto-da-fe,  nor  are  they, 
in  large  cities  at  least,  even  in  danger  of  ostracism.  So,  at 
the  present  day,  it  does  not  require  great  courage  to  be  a 
heretic  or  an  iconoclast.  But  I  wish  to  assure  my  readers 
that  I  have  nothing  but  the  deepest  contempt  for  the  icono- 
clast who  ridicules  old  theories  and  shatters  old  beliefs 
merely  for  the  purpose  of  notoriety,  merely  because  he  wants 
to  shock  people,  merely  because  he  wants  to  be  in  the  lime- 
light for  a  while.  That  my  ideas  run  counter  to  the  gen- 
erally held  beliefs  and  teachings,  is  a  matter  of  regret  to  me. 
But  I  would  not  announce  them  if  I  were  not  perfectly  con- 
vinced in  my  miad,  and  if  I  could  not  prove  it  to  my  per- 
fect satisfaction,  and  to  fair  satisfaction  of  those  who  will 
give  the  matter  an  unbiased  hearing,  that  they  are  right 
and  beneficial,  and  that  the  old  theories  are  wrong  and  per- 
nicious. 

Though  it  is  a  trite  statement,  for  it  has  been  made  so 
many  times,  it  is  nevertheless  true  that  many  text-books  do 
not  present  their  authors'  actual  knowledge  and  personal 

209 


210       GONORRHEA  AND  ITS  COMPLICATIONS 

experience,  but  are  rather  a  resume  of  the  other  text-books 
in  vogue  at  the  given  time.  When  a  man  who  is  writing 
on  a  certain  subject  has  twenty  of  the  most  prominent  text- 
books before  him  and  finds  that- all  or  nineteen  of  them 
make  a  certain  statement,  he  will  be  consciously  or  uncon- 
sciously influenced  by  that  statement.  If  his  experience 
coincides  with  the  statements  of  the  text-books  or  if  he  has 
had  no  experience  in  the  line  covered  by  the  statement,  he 
will  of  course  have  no  hesitation  in  reproducing  that  state- 
ment in  his  writings.  But  suppose  his  experience  differs 
from  or  is  even  diametrically  opposed  to  the  text-book  state^ 
ments — then  he  thinks  that  one  man's  experience  cannot  be 
as  valuable  or  as  deciding  as  that  of  twenty  text-book  writers. 
He  represses  his  doubts,  buries  his  skepticism — and  repro- 
duces the  statement  of  the  authorities.  He  is  unaware  of 
the  fact  that  all  the  twenty  statements  may  and  generally 
do  represent  one  original  source,  one  original  statement  that 
has  been  copied  and  recopied  from  one  text-book  into  an- 
other, without  real  critical  analysis;  he  is  not  aware  of  the 
fact  that  a  "consensus  of  opinion"  is  often  or  occasionally 
but  the  thoughtless  utterance  of  an  unthinking  man  thought- 
lessly repeated  by  a  thousand  other  unthinking  men. 

GONORRHEA  AND   TOBACCO 

For  years  almost  every  text-book  on  the  treatment  of 
gonorrhea  told  us  to  be  sure  to  warn  our  patients  against 
the  use  of  tobacco.  Has  anybody  ever  seen  any  injurious 
effect  of  tobacco  on  the  course  of  a  gonorrhea?  I  am  sure 
not.  And  why  should  there  be  any?  Why  should  the 
smoking  of  tobacco  aid  the  development  of  the  gonococci  or 
increase  the  congestion  in  the  urethra  and  prostate?     If 


GONORRHEA  VS.  SEXUAL  INTERCOURSE      211 

tobacco  has  any  effect  on  the  genital  sphere,  it  is  that  of  a 
sedative,  a  depressant,  and  therefore  cannot  exert  any  in- 
jurious effect.  Of  course  at  the  beginning  of  my  practice 
I  also  forbade  my  gonorrheal  patients  to  smoke ;  but  I  soon 
saw  the  absurdity  of  this  prohibition.  I  saw  that  the  non- 
smoking was  not  only  not  doing  the  patient  any  good,  it 
was  doing  him  actual  harm.  By  making  him  nervous  and 
fidgety,  by  taking  away  his  appetite,  by  disturbing  his  sleep 
(some  people  are  so  used  to  their  smoke  that  by  depriving 
them  of  it  you  interfere  with  all  their  somatic  functions), 
by  interfering  with  the  regular  movement  of  his  bowels  (to 
some  people  a  smoke  is  a  necessity  while  in  the  toilet),  his 
general  condition  was  aggravated,  and  this  of  course  reacted 
deleteriously  on  the  course  of  the  local  disease.  Since  per- 
mitting my  patients  to  smoke  ad  libitum,  I  have  not  had  to 
regret  it  in  a  single  instance,  and  not  only  were  the  patients 
grateful  for  the  permission,  but  the  course  of  their  disease 
was  favorably  influenced  thereby.     Of  this  I  am  sure. 

GONORRHEA   AND  ALCOHOL 

What  I  said  about  the  injunction  against  smoking  applies, 
only  with  much  greater  force,  to  the  injunction  against 
drinking,  i.e.,  drinking  of  alcoholic  beverages.  In  every 
textbook,  in  every  article  written  on  the  subject  it  is  en- 
joined upon  the  patient  not  to  touch  a  drop  of  anything  con- 
taining C2H5OH  in  any  shape  or  form.  Dire  results  are 
threatened  in  the  case  of  an  infraction  of  this  injunction. 
That  in  the  acute  florid  state  of  gonorrhea  alcohol  in  any 
form  is  best  abstained  from  is  granted;  but  I  emphatically 
deny  that  there  is  any  valid  reason  for  denying  alcohol  to 
those  suffering  with  chronic  gonorrhea  or  urethritis.     I  even 


212       GOXOKRHEA  AND  ITS  CO^MPLICATIONS 

question  if  it  is  necessary  to  prohibit  alcoholic  beverages  ab- 
solutely in  the  declining  stage  of  an  acute  gonorrhea. 

Though  perhaps  too  personal  a  matter,  it,  for  certain  rea- 
sons, may  not  be  amiss  to  state  here  that  the  writer  is  prac- 
tically a  total  abstainer.  What  he  consumes  in  alcoholics 
would  not  yield  to  the  government  two  cents  per  annum  in 
revenue  tax.  It  is  not  therefore  out  of  pei'sonal  predilection 
that  he  pleads  for  not  depriving  the  patients  entirely  of 
every  kind  of  alcoholic  beverage  that  they  have  been  used  to, 
but  because  he  is  convinced  that  such  deprivation  often 
works  direct  and  positive  injury  to  the  patient. 

]\Iany,  many  years  ago,  a  member  of  the  tonsorial  guild 
told  me  while  trimming  my  hair  that  in  his  opinion  the  doc- 
tors as  a  class  did  not  know  very  much  (of  coui^se,  there  were 
exceptions,  he  hastened  to  add).  He  had  a  gleet,  oh,  for 
ever  so  long.  He  went  from  dispensary  to  dispensary,  doc- 
tor to  doctor,  they  all  gave  him  different  injections  and  told 
him  to  keep  away  from  liquor ;  but  he  wasn  't  getting  better. 
He  finally  got  disgusted,  got  drunk  one  evening,  kept  on 
drinking  beer — and  very  soon  he  was  well.  What's  more, 
since  then  he  gave  that  advice,  to  drink  beer,  to  a  number 
of  people  and  most  of  them  got  better.  Yes,  some  got  worse. 
I  smiled  then  at  the  ignorance  of  my  barber,  but  in  later 
years  I  came  to  think  of  his  story.  I  had  a  patient,  a 
Frenchman,  who  from  his  earliest  youth  was  in  the  habit 
of  taking  a  glass  of  claret  with  his  principal  meal  or  meals. 
I  forbade  him  the  claret.  He  was  unable  to  eat.  Eating 
without  zest,  he  got  dyspepsia,  and  his  bowels  became  very 
constipated,  which  made  his  gonorrhea  worse.  He  went  on 
like  that  for  about  two  weeks,  but  then  he  said  he  could 


GONORRHEA  VS.  SEXUAL  INTERCOURSE   213 

stand  it  no  longer.  I  permitted  him  then  to  have  his  claret. 
Not  only  his  general  condition,  but  his  gonorrhea  also  im- 
proved. These  and  similar  things  set  me  thinking,  and  I 
began  to  observe  cause  and  effect — and  I  have  ceased  threat- 
ening my  gonorrhea  patients  with  dire  consequences  if  they 
did  not  abstain  from  all  alcoholic  beverages.  And  I  still 
have  no  cause  to  regret  my  liberality  in  this  respect.  Many 
cases  of  chronic  urethritis  are  distinctly  improved  by  the 
moderate  consumption  of  beer  and  wine. 

GONORRHEA   AND   SEXUAL  INTERCOURSE 

In  spite  of  the  elaborate  introduction  at  the  head  of  this 
article,  I  confess  that  it  is  with  some  trepidation  that  I  ap- 
proach this  subject.  But  it  is  better  to  get  at  once  in 
medias  res.  A  decent  man  with  acute  gonorrhea,  with  pro- 
fuse discharge,  with  ardor  urinse,  painful  chordee,  etc.,  will 
not  think  of  having  intercourse.  Not  that  he  has  no  desire — 
the  libido  is  only  too  frequently  heightened  in  all  stages  of 
gonorrhea^ — ^but  common,  ordinary  decency  will  restrain  him 
from  satisfying  his  desire,  even  if  he  did  not  know  that  in- 
dulgence might  prove  injurious  to  him.  But  from  advising 
abstinence  in  the  acute  stage  is  a  wide  gap  to  the  strict 
prohibition  of  all  sexual  relations  during  the  entire  course 
of  a  chronic  urethritis,  no  matter  of  how  long  a  duration. 
It  is  not  merely  that  such  abstinence  is  unnecessary.  If  it 
were  only  that,  it  would  hardly  be  worth  while  broaching 
the  subject.  But  such  abstinence  is  injurious,  injurious  to 
the  gonorrhea  itself,  and  when  this  is  the  case  it  becomes 
the  duty  of  the  physician  to  speak.  And  I  will  say  clearly 
that  many  cases  of  chronic  urethritis,  gonorrheal  and  non- 


214       GONORRHEA  AND  ITS  COMPLICATIONS 

gonorrheal,  are  unmistakably  benefited  by  sexual  inter- 
course. Nor  is  it  hard  to  understand  the  reason.  A  little 
thought  will  make  the  rationale  perfectly  clear. 

A  perfectly  healthy  person,  who  has  led  a  normally  ac- 
tive sexual  life,  will  often,  when  obliged  for  one  reason  or 
another  to  forego  sexual  relations  for  a  considerable  period, 
begin  to  suffer  from  a  certain  congestion  in  the  genital 
organs.  The  testicles  will  feel  heavy  and  painful,  there  will 
be  irritation  and  radiating  pains  in  the  prostatic  region,  etc. 
These  symptoms  are  much  more  aggravated  in  gonorrhea. 
The  libido  is,  as  is  well  known,  frequently  greatly  ex- 
aggerated in  gonorrhea.  This  is  due  to  the  local 
congestion  in  the  organs.  If  a  man  is  suffering  from 
subacute  or  chronic  urethritis  or  prostatitis,  and  you 
forbid  him  to  have  any  sexual  relations  for  several 
months,  you  surely  aggravate  all  his  symptoms,  increase  the 
congestion,  and  make  the  local  condition  much  more  difficult 
to  cure.  Sometimes  you  make  a  cure  impossible.  And  in 
fact  nature  often  rebels  at  and  scorns  your  injunctions,  and 
to  your  orders  of  perfect  abstinence  she  often  replies  with 
nightly  emissions,  which  hurt  a  patient  much  more  than 
normal  coitus  would.  It  is  a  well  known  fact  that  many 
gonorrheal  patients  begin  to  suffer  for  the  first  time,  during 
their  illness,  with  very  annoying  and  frequently  repeated 
pollutions.  A  little  thought  will  show  us  that  a  normal 
coitus  accomplishes  in  a  simple,  pleasant  and  complete  man- 
ner what  we  are  trying  to  do  therapeutically  in  a  crude, 
painful,  incomplete  and  not  infrequently  harmful  manner. 
In  our  treatment  we  try  to  bring  the  gonococci  hidden  in  the 
various  urethral  glands  and  lacunge  to  the  surface.  We  do 
this  partly  with  our  injections,  partly  by  massage  of  the 


GONORRHEA  VS.  SEXUAL  INTERCOURSE   215 

urethra,  and  now  we  have  even  introduced  the  vacuum 
suction  treatment,  which  has  this  purpose  in  view.  We 
massage  the  prostate  and  strip  the  seminal  vesicles — fre- 
quently with  quite  some  traumatism  to  these  two  organs — 
and  for  what  purpose  ?  To  free  the  prostate  and  the  seminal 
vesicles,  as  far  as  possible,  of  the  gonococci  and  the  catarrhal 
or  purulent  products  which  they  may  contain.  I  maintain, 
then,  that  a  satisfying,  normal  coitus — not  coitus  inter- 
ruptus,  or  reservatus,  or  retardatus,  but  a  perfectly  normal 
coitus — will  accomplish  this  purpose  in  a  much  more  com- 
plete manner,  and  without  any  injury  to  the  patient.  (For 
I  must  again  mention  that  massage  of  the  prostate  and  par- 
ticularly stripping  of  the  vesicles,  except  in  very  expert  and 
gentle  hands,  is  not  an  indifferent  procedure.  The  vesicles 
have  more  than  once  been  irretrievably  damaged  by  rough 
milking  or  stripping.)  He  who  has  had  an  opportunity  of 
examining  the  prostate  and  vesicles  before  and  after  coitus 
will  testify  how  completely  they  may  be  emptied  by  the 
process  of  sexUal  intercourse.  Certainly  much  more  com- 
pletely than  any  massage  or  stripping  ever  can.  The  fact 
that  both  the  subjective  and  objective  symptoms  in  a  chronic 
gonorrheic  are  frequently  markedly  improved  after  coitus 
speaks  in  favor  of  the  latter. 

Here  the  hypercritical  might  interpose:  If  intercourse 
is  not  only  not  harmful  but  distinctly  beneficial  in  chronic 
gonorrhea,  why  is  it  not  also  beneficial  in  acute  gonorrhea, 
and  why  not  also  recommend  it  in  that  condition  ?  Because 
we  have  an  entirely  different  condition  to  deal  with.  In 
acute  gonorrhea  we  have  an  acute  active  hyperemia; 
all  the  blood  vessels  are  overfilled  with  blood  and  to 
bring   an   additional   flow   of   blood   would   still    further 


216       GONORRHEA  AND  ITS  COMPLICATIONS 

distend  the  blood  vessels  and  erectile  tissues,  and  might 
cause  an  edema,  by  transudation.  In  acute  gonorrhea 
we  must  avoid  anything  which  will  cause  an  erection, 
as  the  penalty  might  be  a  painful  chordee.  In  chronic 
gonorrhea  we  have  but  a  slight,  generally  passive  localized 
hyperemia;  we  may  even  have  an  ischemia.  The  effect, 
therefore,  is  not  the  same.  What  is  good  in  one  stage  of 
gonorrhea  might  be  distinctly  injurious  in  another  stage. 
Our  critic  might  as  well  ask:  If  a  two  to  ten  per  cent, 
solution  of  silver  nitrate  is  so  beneficial  in  chronic  ure- 
thritis, why  not  also  use  it  in  acute  urethritis  ?  if  massage 
is  useful  in  chronic  prostatitis,  why  not  use  it  also  in  acute 
inflammation  of  the  prostate  ? 

So  far,  I  have  spoken  of  the  man  only.  "We  now  come 
to  the  woman.  The  woman  must,  of  course,  be  protected 
at  all  hazards.  If  the  woman  cannot  be  protected  abso- 
lutely then  the  man  must  abstain  absolutely,  no  matter  how 
injurious  the  results  of  abstinence  may  be  to  him.  Fortu- 
nately the  woman  can  be  protected.  A  proper  condom  is 
a  perfect  protection,  but  unluckily  it  is  not  satisfactory  as 
far  as  the  man  is  concerned.  Coitus  condomatus  does  not 
do  what  we  want  it  to  do  in  emptying  the  prostate  and 
vesicles,  and  does  often  leave  the  man  in  an  unsatisfied  and 
irritable  condition.  This  is  true  of  normal  men  and  is 
still  more  true  of  men  with  some  venereal  and  sexual 
trouble.  But  it  is  not  necessary  to  depend  upon  the  con- 
dom. A  perfectly  safe  way  is  the  insertion  by  the  woman 
of  a  mild  antiseptic  suppository  a  few  minutes  before  coitus 
(one  containing  salicylic  acid,  boric  acid,  chinosol,  etc.), 
and  the  use  after  of  a  mild  antiseptic  douche.  This  method 
has  been  used  in  very  many  cases.    And  there  has  not  been 


GONORRHEA  VS.  SEXUAL  INTERCOURSE   217 

a  single  case  of  infection.  None  has  come  to  my  notice, 
and  I  am  certain  that  I  would  have  heard  of  them  if  any 
had  occurred,  because  it  was  done  by  my  advice,  and  if 
infection  had  taken  place  the  responsibility  would  have 
been  thrown  on  my  shoulders. 

I  might  add  here  that  many  men  who,  soon  after  marriage 
or  on  the  point  of  getting  married,  find  that  their  gonor- 
rhea, which  they  thought  was  perfectly  cured,  is  still  un- 
cured,  have  been  advised  this  method,  and  in  no  instance 
was  a  wife  ever  infected. 

In  conclusion  I  might  say  that  abstinence  during  a  long 
drawn  out  case  of  chronic  urethritis — an  abstinence  last- 
ing months  or  one  or  two  years,  for  there  are  cases  of 
urethritis  lasting  that  long — ^has  another  injurious  effect; 
namely,  it  is  apt  to  affect  a  man's  sexual  potency.  But 
this  is  a  point  that  does  not  belong  in  this  book. 


CHAPTER  XXXII 
GONORRHEA  IN  WOMEN 

When  a  man  has  gonorrhea  he  knows  it.  While  (having 
learned  long  ago  not  to  be  dogmatic  about  anything  in 
medicine)  I  do  not  deny  the  possibility  of  a  symptomless 
or  practically  symptomless  gonorrheal  urethritis  in  the  male, 
still  such  cases,  if  at  all  existent,  must  be  extremely  rare. 
This  is  not,  however,  the  case  with  women.  A  woman  may 
go  through  an  acute  gonorrhea  from  beginning  to  end  with- 
out knowing  it,  may  have  a  chronic  gonorrhea  for  years 
without  being  aware  of  its  existence,  often  sincerely  believ- 
ing that  she  is  perfectly  well.  A  man  is  not  used  to  having 
pains  or  burning  in  his  urethra,  nor  is  he  used  to  having 
any  discharge  from  it.  At  the  least  pain  or  scalding,  or 
the  least  appearance  of  discharge,  he  knows  there  is  some- 
thing wrong  with  him.  The  urethra  when  infected  in 
women  does  not  give  as  severe  symptoms  as  inflammation 
of  the  urethra  in  men,  and  besides  in  many  cases  the  female 
urethra  escapes  infection,  the  infection  being  limited  to  the 
cervix  alone  or  to  the  cervix  and  Bartholin's  glands. 

A  woman  is  used  to  pains,  the  premenstrual  pains  with 
which  many  of  them  suffer  are  severer  than  the  pains  caused 
by  the  gonorrheal  infection ;  and  they  often  have  a  leucor- 
rheal  discharge  of  greater  or  lesser  degree.  An  increase  in 
the  amount  of  secretion  or  in  its  color  and  consistency  does 
not  attract  their  attention.     It  is  for  this  reason  that  many 

218 


GONORRHEA  IN  WOMEN  219 

women  harbor  the  gonococcus  for  months  before  applying 
to  a  physician,  and  some  of  them  never  apply  at  all.  It  is 
as  a  rule  when  the  discharge  is  very  profuse,  offensive  and 
irritating,  when  urination  is  painful  and  burning,  or  when 
there  is  a  sharp  salpingeal  attack,  that  the  physician's  aid 
is  invoked. 

I  repeat  that  many  women  go  through  life  with  a  chronic 
gonorrheal  cervicitis,  with  an  abundant  discharge  contain- 
ing numerous  gonococci,  and  use  no  treatment  except  an 
occasional  douche,  because  they  are  under  the  impression 
that  they  are  suffering  from  the  ordinary  leucorrhea  or 
"whites"  (just  as  if  leucorrhea  itself  did  not  require  intel- 
ligent medical  treatment). 

I  do  not  wish  to  be  understood  as  claiming  that  gonorrhea 
in  the  female  is  always  of  a  mild  character,  pursuing  a  sub- 
acute or  symptomless  course.  I  mean  to  say  that  such  are 
the  vast  majority  of  cases  which  present  themselves  to  the 
physician  who  has  a  "respectable"  practice.  In  the  vast 
majority  of  cases  of  respectable  married  women  the  disease 
pursues  such  a  subacute  course.  Why?  Because  in  them 
the  infection  when  it  takes  place  is  usually  the  result  of 
chronic  gonorrhea  in  the  husband.  No  half-way  respect- 
able man  will  enter  matrimony  when  suffering  with  an  acute 
gonorrhea,  and  only  an  exceptionally  brutal  or  weak-minded 
husband,  who,  straying  from  the  path  of  marital  fidelity, 
has  acquired  an  acute  gonorrhea,  will  continue  to  have 
relations  with  his  wife.  And  here  is  the  point  I  wish  to 
make.  When  the  infecting  man  is  suffering  with  a  chronic 
gonorrhea,  the  infection  in  the  woman  usually  pursues  a 
subacute  or  chronic  course.  But  when  the  man  has  an 
acute  gonorrhea  then  the  infection  in  the  woman  may  from 


220       GONORRHEA  AND  ITS  COMPLICATIONS 

the  very  beginning  assume  a  superacute,  even  fulminajit  | 
character.  And  the  rapidity  with  which  the  infection  may 
show  itself  is  remarkable.  While  several  days  usually 
elapse  between  the  infecting  intercourse  and  the  first  symp- 
toms, there  are  cases  in  which  the  latter  show  themselves  in 
24  hours,  and  I  have  had  a  case  where  a  bride,  a  girl  of 
twenty-one,  had  her  first  intercourse  at  midnight,  and  the 
following  noon  she  began  to  complain  of  burning,  irrita- 
tion, scalding  urination,  etc.  In  short,  the  symptoms 
showed  themselves  in  twelve  hours  after  the  infecting  in- 
tercourse. In  her  case  the  gonorrhea  proved  of  a  viru- 
lent character;  the  contributing  factors  were  the  frequent 
repetition  of  the  act  during  the  night  (five  or  six  times) 
and  the  violence  with  which  it  was  performed.  The  de- 
floration, which  leaves  an  open  raw  wound,  was  also  a  con- 
tributing factor  in  this  case,  as  it  is  in  many  other  cases. 

While  it  usually  takes  months  for  a  salpingitis  to  develop 
as  the  result  of  gonorrheal  infection,  there  are  cases  in 
which  distinct  symptoms  of  inflammation  of  the  Fallopian 
tubes  may  develop  within  a  few  days,  or  even  within  a 
few  hours  after  an  infecting  intercourse.  In  such  cases 
we  are  forced  to  believe  in  the  suction  action  of  the  uterus. 
It  is  impossible  to  believe  that  the  infection  reached  the 
Fallopian  tubes  by  continuous  extension,  within  such  a 
short  period.  It  is  more  plausible  to  believe  that  the  in- 
fection took  place  by  the  infecting,  gonocoeci-containing 
material  being  sucked  up  into  the  uterus  and  into  the 
Fallopian  tubes.  This  appears  to  be  more  likely  from  the 
fact  that  a  gonorrheal  salpingitis  may  exist  without  an 
intervening  endometritis  or  metritis. 

The  symptoms  in  an  acute  or  superacute  case  of  gonor- 


GONORRHEA  IN  WOMEN  221 

rhea  may  be  very  severe.  Within  several  days  after  an 
infecting  intercourse,  and  sometimes  within  several  hours, 
the  latter  particularly  in  young  virgin  brides  and  still 
more  particularly  if  the  act  is  performed  stormily  and 
repeatedly,  the  woman  begins  to  complain — or  if  not  to 
complain,  then  to  experience,  because  many  of  them  do  not 
complain  until  their  condition  becomes  unbearable — of  a 
burning  and  itching  in  the  vulva  and  vaginal  introitus, 
of  frequent  urination,  accompanied  by  strangury,  and  a 
scalding  sensation.  A  discharge  soon  makes  its  appearance, 
which,  according  to  the  severity  of  the  case,  may  be  creamy, 
cream-yellow  or  greenish.  It  may  possess  little  odor  or 
be  extremely  offensive.  It  is  often  very  irritating,  eroding 
the  skin  with  which  it  comes  in  contact  and  causing  pruri- 
tus and  intertrigo  around  the  genitals,  anus,  thighs,  etc. 
If  proper  cleanliness  is  not  observed,  the  infecting  dis- 
charge may  invade  the  anus  and  a  gonorrheal  proctitis  be 
the  result.  There  is  usually  an  elevation  of  temperature, 
100°  to  102°  F.,  there  may  also  be  a  chill,  and  the  feeling 
of  general  malaise  may  be  quite  pronounced.  If  the  in- 
fection involves  also  the  Fallopian  tubes,  then  all  the  gen- 
eral symptoms  may  be  greatly  aggravated.  The  chill  may 
be  quite  severe,  the  temperature  may  go  up  to  103°  or 
even  104°  F.,  the  abdomen  is  tender,  and  the  feeling  of 
malaise  may  be  so  severe  as  to  create  apprehension  of  a 
general  peritonitis. 

The  diagnosis  of  an  acute  or  superacute  case  of  gon- 
orrhea in  the  female  presents  no  difficulties.  The  history 
and  the  symptoms  as  related  by  the  patient  are  alone  suf- 
ficient. Inspection  of  the  genitals,  covered  with  pus,  the 
introduction  of  a  speculum,  which  shows  us  an  inflamed 


222      GONORRHEA  AND  ITS  COMPLICATIONS 

eroded  cervix,  bleeding  at  the  slightest  touch,  and  bathed 
in  pus  which  oozes  from  its  external  os,  make  the  diagno- 
sis certain.     No  bacteriological  examination  is  necessary. 

THE   TREATMENT 

I  know  of  no  condition  in  medicine  where  noli  nocere 
is  more  important  than  in  treating  gonorrhea  of  the  female. 
It  is  just  as  important  to  know  what  not  to  do  and  not 
do  it  as  it  is  to  know  what  to  do  and  to  do  it.  In  other 
words,  negative  treatment  is  here  as  important  as  posi- 
tive treatment.  In  fact  abstaining  from  doing  certain 
things  is  often  the  more  important  part  of  the  treatment. 

The  great,  the  paramount  point  in  treating  gonorrhea 
in  women  is  to  prevent  the  disease  from  passing  the  internal 
OS  and  spreading  through  the  endometrium  into  the  tubes, 
and  from  there  into  the  ovaries  and  peritoneum.  As  long 
as  we  can  keep  the  gonorrheal  process  limited  to  the  cervix 
and  the  other  external  genitals,  gonorrhea  is  not  a  ter- 
rible disease.  We  can  handle  it  without  great  difficulty 
and  cure  it  eventually,  though  the  time  required  for  a  cure 
may  in  some  cases  be  exasperatingly  long.  It  is  when  the 
gonorrheal  process  is  extended  above  the  internal  os,  that 
we  become  helpless.  For  after  the  process  has  involved 
the  endometrium  and  the  Fallopian  tubes  there  is  no  medi- 
cal treatment;  there  is  only  expectant  and  surgical  treat- 
ment, which  is  of  course  no  treatment  at  all  in  the  true 
sense  of  the  word.  Removing  the  tubes  may  be  necessary 
to  save  the  patient's  life,  but  to  cut  out  an  organ  is  not 
to  cure  it. 

Unfortunately  it  is  here  that  physicians  have  sinned 
jnost  pitifully.     I  have  no  hesitation  in  saying— it  is  pain- 


GONOKKHEA  IN  WOMEN  223 

ful  to  say  it  but  nothing  is  gained  by  hiding  the  truth — 
that  a  large  percentage  of  eases  of  endometritis  and  metri- 
tis, salpingitis,  and  peritonitis,  that  thousands  and  thou- 
sands of  cases  requiring  surgical  interference  are  due  di- 
rectly to  the  physician's  well-meant  energetic  treatment. 
The  introduction  of  syringes  and  probes  into  the  cervix, 
the  scraping  and  cauterizing  with  strong  caustic  solutions, 
are  in  many  instances  directly  responsible  for  the  exten- 
sion of  the  inflammation  and  for  the  aggravation  of  the 
patient's  condition.  Those  who  know  anything  about  the 
treatment  of  gonorrhea  in  women  and  are  not  obsessed  by 
the  furor  operandi,  know  that  we  get  the  best  results  by  the 
gentlest  methods  and  mildest  applications. 

I  consider  these  prefatory  remarks  of  extreme  impor- 
tance, for  until  the  physician  is  imbued  with  the  feeling, 
saturated  with  the  conviction:,  that  brutality  is  not  a  neces- 
sary element  in  the  treatment  of  gonorrhea,  that  too  ener- 
getic treatment  is  often  injurious  instead  of  beneficial,  that 
the  uterine  cavity  must  at  all  hazards  be  protected  from  an 
extension  of  the  inflammation,  and  that  he  at  least  must 
not  be  the  causative  factor  of  that  extension,  until  he  is 
convinced  of  all  these  things  he  is  not  a  safe  person  to 
undertake  the  treatment  of  a  case  of  gonorrhea  in  a  woman. 

General  Treatment.  The  general  treatment  of  acute 
gonorrhea  in  the  female  can  be  expressed  in  one  word  or 
phrase :  rest,  taking  it  easy.  If  we  wish  to  avoid  a  salping- 
itis or  extension  of  the  inflammation  above  the  internal  os 
this  is  a  conditio  sine  qua  non.  It  is  unfortunate  that  many 
women,  and  respectable  married  women  at  that,  still  must 
keep  on  doing  their  household  work  or  other  heavy  work. 
Where  it  is  unavoidable  it  is  unavoidable  and  that  is  all 


224      GONOERHEA  AND  ITS  COMPLICATIONS 

there  is  to  it,  but  the  proper  thing  would  be  to  put  the 
woman  to  bed,  or  at  least  keep  her  in  her  room  for  a  couple 
of  weeks  and  have  her  take  things  very  easy. 

Where  there  is  a  considerable  rise  in  temperature  or 
symptoms  of  salpingitis  seem  to  be  threatening  then  put- 
ting the  patient  to  bed  is  imperative  and  applying  an 
ice-bag  to  the  abdomen  is  very  useful. 

Coitus  must  be  absolutely  interdicted.  One  can  think  of 
nothing  more  harmful,  more  dangerous,  than  coitus  for  a 
woman  affected  with  gonorrhea.  Intercourse  is  bad  for  a 
male  with  acute  gonorrhea,  but  it  is  very  much  more  danger- 
ous for  a  female  gonorrheic  patient.  It  not  only  aggra- 
vates the  existing  condition,  increasing  the  inflammation  in 
the  vulva,  urethra  and  cervix,  but  it  is  about  the  surest 
way  to  cause  a  salpingitis.  I  have  known  cases  which  were 
progressing  very  nicely,  which  were  on  the  point  of  re- 
covery, but  which  became  suddenly  aggravated  and  in 
which  symptoms  of  salpingitis  became  evident  immediately 
after  coitus.  So  this  must  be  forbidden  absolutely  in  all 
acute  and  subacute  cases  of  gonorrhea.  No  exceptions  can 
be  permitted.  Whether  this  extension  of  the  inflammation 
is  due  simply  to  the  engorgement  of  the  uterus  and  other 
genital  parts  induced  by  the  coitus  or  to  a  certain  suction 
and  peristaltic  action  of  the  uterus  is  immaterial.  Both 
may  be  causative  factors.  The  fact  remains  that  coitus 
is  a  dangerous  procedure,  which  may  lead  to  a  fatal  issue, 
for  a  woman  suffering  with  acute  or  subacute  gonorrhea. 
A  man  who  forces  a  woman  in  such  condition  to  submit 
to  intercourse  is  a  criminal  brute  and  the  woman  who  sub- 
mits to  it  is  a  pitiful  slave.  And  stiU  the  woman  is  often 
forced  to  submit  to  it,  the  husband  thinking  that  if  he 


GONORRHEA  IN  WOMEN  225 

uses  a  condom  and  is  not  too  violent  he  has  done  every- 
thing necessary  to  protect  himself  and  her. 

As  far  as  the  diet  is  concerned,  little  or  no  change  need 
be  made  in  it  if  the  urethra  is  not  involved.  Spices  and 
alcohol,  however,  are  best  omitted,  as  they  do  perhaps 
cause  congestion  of  the  genitalia  and  thus  aggravate  the 
condition.  But  where  there  is  a  urethritis  practically  the 
same  restrictions  are  indicated  as  in  gonorrhea  of  the  male. 

As  far  as  internal  treatment  is  concerned,  none  is  nec- 
essary unless  the  urethra  is  involved.  When  the  urethra 
is  involved  and  urination  is  painful,  then  we  may  give  the 
same  balsams,  hyoscyamus  and  alkalies  as  we  do  in  ure- 
thritis of  the  male. 

The  Local  Treatment.  If  the  local  treatment  in  male 
urethritis  is  important,  it  is  much  more  so  in  gonorrhea 
of  the  female.  In  fact  it  is  the  only  part  of  the  treat- 
ment from  which  definite  results  can  be  obtained,  the  in- 
ternal treatment  being  merely  occasional  and  auxiliary. 
The  treatment  to  be  successful  must  be  of  two  kinds;  one 
administered  by  the  physician,  the  other  administered  by 
the  patient  or  to  the  patient  in  her  home.  The  home  treat- 
ment consists  in  the  use  of  injections  and  suppositories. 
The  medical  treatment,  that  is  the  treatment  on  the  part  of 
the  physician,  consists  in  local  applications,  that  is  in 
swabbing  and  painting  the  parts,  and  occasionally  in  cau- 
terizing. Both  parts  of  the  treatment  are  necessary,  as 
they  supplement  each  other. 

As  stated  before,  the  home  treatment  consists  in  the  use 
of  vaginal  douches  and  suppositories.  The  injections  that 
I  prefer  to  all  others  are  iodine,  lactic  acid,  and  a  combina- 
tion of  alum,  zinc  sulphate  and  copper  sulphate.     Where 


226      GONORRHEA  AND  ITS  COMPLICATIONS 

the  discharge  is  very  profuse  the  injections  should  be  given 
as  often  as  four  times  a  day.  After  the  discharge  becomes 
less  profuse,  twice  a  day  and  then  once  a  day  is  sufficient. 
The  iodine  injections  are  made  by  adding  one  tablespoonful 
of  tincture  of  iodine  to  two  quarts  of  hot  water.  In  some 
cases  this  is  too  irritating  and  we  may  commence  with  a 
teaspoonful  to  two  quarts  of  water.  The  lactic  acid  is  used 
in  the  strength  of  1-500  to  1-1000.  The  alum,  zinc,  copper 
combination  has  the  following  formula: 

Aluminis §iv 

Zinci  sulphatis §i 

Cupri  sulphatis 3iv 

Sig.     Tablespoonful  to  1  or  2  quarts  of  water. 

The  injections  or  douches  should  invariably  be  taken  in 
the  recumbent  position,  the  patient  lying  flat  on  her  back 
on  a  flat  douche  pan.  It  is  better  when  the  buttocks  are 
raised,  so  that  they  are  on  a  higher  level  than  the  rest  of 
the  body.  The  injection  is  given  very  slowly,  the  fountain 
syringe  hanging  but  high  enough  to  permit  the  liquid  to 
run  out.  After  each  injection  the  patient  should  remain 
for  half  an  hour  or  at  least  fifteen  minutes  flat  on  her  back. 
This  permits  some  of  the  liquid  that  remains  in  the  vagina 
to  bathe  the  vaginal  walls  and  the  cervix.  In  the  average 
case  I  order  two  vaginal  douches  a  day:  in  the  morning, 
either  the  iodine  or  the  lactic  acid  solution,  in  the  evening 
the  astringent  powder.  Where  three  or  four  injections  a 
day  are  ordered  they  are  used  in  alternation.  There  is  no 
doubt  as  to  the  good  effect  of  these  injections.  Not  only 
do  they  keep  the  parts  clean  and  mechanically  remove  the 
discharge,  which  is  such  a  good  nutrient  medium  for  the 


GONOERHEA  IN  WOMEN 


227 


various  saprophytic  bacteria,  but  they  also  have  a  gono- 
cidal  effect,  heal  erosions  and  congestions  and  help'  materi- 
ally the  doctor's  work. 

The  nozzle  which  is  used  for  the  vaginal  injections  is  not 
a  matter  of  indifference.  I  recommend  the  nozzle,  an  illus- 
tration of  which  is  reproduced  herewith.  It  possesses  two 
important  advantages.  First,  it  can  close  the  vaginal 
outlet  completely  and  tightly,  so  that  by  closing  the  clamp 
of  the  outlet  pipe,  the  vagina  can  be  ballooned  out,  filled 


Vaginal   Nozzle,   possessing   several   advantages 

with  the  antiseptic  solution  and  every  part  of  the  cervix  and 
the  vaginal  folds  thoroughly  cleansed.  Second,  with  it  we 
can  use  solutions  of  much  higher  temperatures  than  without 
it.  As  is  well  known,  the  vagina  and  cervix  can  stand  very 
high  temperatures ;  it  is  the  vulva  that  is  sensitive,  and  with 
the  ordinary  pipe  or  nozzle  the  heat  of  the  outflowing  liquid 
causes  discomfort  or  burning.  With  this  nozzle  the  out- 
flowing liquid  passes  through  a  separate  pipe  and  does  not 
touch  the  vulva.  The  use  of  a  solution  of  a  high  tempera- 
ture (120°  F.  and  higher)  possesses  a  double  value.  It  is  in 
itself  gonococcocidal,  and  helps  in  the  absorption  of  ex- 
udates if  any  be  present. 


228       GONORRHEA  AND  ITS  COMPLICATIONS 

In  some  severe  cases  I  also  order  suppositories,  one  sup- 
pository to  be  introduced  at  night.  The  suppositories  usu- 
ally contain  as  their  active  constituent  either  protargol  or 
the  lactic  acid  bacillus.  The  formulas  of  these  supposi- 
tories are  as  follows: 

Protargol    gr.  v 

Olei  theobromatis 31 

M.  ft.  suppos.  ovale  vel.  glob.  No.  I 
D.  Tal.  Dos.  No.  XII. 

Sig.     One  at  night ;  to  be  inserted  high  up  in 
the  vagina. 
^  Bacillus  bulgaricus  tablets,  gr.  x 
01.  theobromatis,  gr.  xxx 
M.  f.  suppos.  No.  I.     Tal.  Dos.  xx 
S.     One  night  and  morning. 
Instead  of  suppositories,  the  bacillus  bulgaricus  may  be 
prescribed  mixed  with  sugar  and  blown  into  the  vagina  by 
means  of  an  insufflator. 

The  Doctor's  Treatment.  The  patient  comes  to  the 
office  always  immediately  after  having  taken  a  thorough 
douche.  The  only  time  the  douche  is  left  out  is  when  the 
doctor  wants  to  make  a  bacteriologic  examination  of  the 
secretions.  He  wipes  off  the  vulva,  examines  carefully  for 
any  inflamed  points  or  erosions,  and  if  there  are  any  he 
touches  them  with  silver  nitrate  10  to  50  per  cent., 
or  even  with  the  silver  nitrate  stick.  The  ducts  of  Bar- 
tholin's glands  are  examined  carefully,  an  attempt  is  made 
to  express  any  pus,  and  if  found  necessary  they  are  cau- 
terized with  a  thin  probe  or  a  10  per  cent,  silver  nitrate 


GONORRHEA  IN  WOMEN  229 

solution  is  injected  into  them  by  means  of  a  hypodermic 
syringe  with  a  blunted  needle.  The  urethra  is  next  ex- 
amined and  if  affected  is  swabbed  with  a  5  to  10  per  cent, 
silver  nitrate  solution.  As  a  rule  the  urethra  responds  to 
treatment  very  readily.  I  have  no  use  for  any  urethral 
bougies  or  suppositories  in  women  any  more  than  I  have 
for  them  in  men.  The  vagina  is  next  examined  witii  a 
speculum  and  a  good  light,  and  erosions,  if  any,  are  touched 
with  silver  nitrate  solution,  10  per  cent.,  or  tincture  of 
iodine  full  strength.  Lactic  acid  full  strength  is  also  a 
good  application. 

"We  then  come  to  the  cervix,  which  is  the  most  important 
part  of  the  treatment.  We  wipe  it  off  as  carefully  as  we 
can,  introduce  several  cotton-wound  probes  and  try  to  re- 
move the  cervical  plug.  The  entire  cervix  is  then  painted 
with  tincture  of  iodine,  and  a  thin  cotton  swab  dipped  into 
tincture  of  iodine  is  gently  introduced  into  the  os.  Care  is 
taken  not  to  pass  the  internal  os,  though  if  it  should  pass 
the  danger  of  extension  of  the  infection  would  be  nil  or 
practically  nil.  Iodine  is  one  of  the  best  agents  we  have  in 
treating  gonorrhea  in  the  female,  and  while  I  still  use  sil- 
ver nitrate  applications  to  the  vagina,  vulva  and  urethra, 
as  far  as  the  cervix  is  concerned  I  limit  myself  exclusively 
to  iodine.  My  results  have  been  much  better  since  exchang- 
ing silver  nitrate  for  iodine,  because  silver  nitrate  denudes 
the  delicate  surface  of  the  cervix  and  may  perhaps  be  in^ 
fluential  in  causing  an  extension  of  the  inflamjaation.  In- 
stead of  a  probe  a  thin  long  uterine  syringe  may  be  used 
and  a  few  drops  of  tincture  of  iodine  may  be  deposited  in 
the  cervix. 

When  the  infection  has  spread  into  the  endometrium  and 


230       GONORRHEA  AND  ITS  COMPLICATIONS 

the  tubes,  then  it  really  ceases  to  be  a  genito-urinary  and 
becomes  a  gynecological  case.  But  the  gynecological  sur- 
geon can  do  medicinally  no  more  than  the  ordinary  physi- 
cian unless  it  is  a  case  which  demands  operation.  The 
proper  treatment  of  endometritis  and  salpingitis  is  rest,  hot 
or  cold  applications  by  means  of  compresses  or  poultices  to 
the  abdomen,  and  tampons  of  gauze  saturated  in  glycerite 
of  boro-glycerin  or  ichthyol-glycerin  or  thigenol-glycerin. 
That  is  all  we  can  do  and  that  is  all  we  should  do.  In- 
jecting or  swabbing  the  uterus  with  caustic  or  strong  anti- 
septic applications,  scraping  or  curetting  the  uterus,  all 
these  are  brutal  and  useless  procedures;  not  only  useless 
but  injurious.  They  may  do  good  in  some  cases  but  the 
cases  in  which  they  do  harm  are  so  much  in  preponderance 
that  no  conscientious  physician  should  employ  them.  We 
can  never  be  sure  of  removing  all  the  germs  by  these  meas- 
ures, while  we  are  pretty  sure  to  cause  their  further  spread 
and  development  and  to  aggravate  the  inflammation. 
Curetting  is  not  abused  so  much  now  as  it  was  formerly, 
but  it  is  still  practiced  ten  times  more  often  than  it  should 
be.  Hot  baths,  particularly  pretty  concentrated  sea-salt 
baths,  are  useful  in  aiding  the  absorption  of  exudates. 
And  I  repeat  that  unless  the  case  is  a  distinctly  surgical 
case,  demanding  surgical  intervention,  this  is  all  the  gyne- 
cologist, genito-urinary  surgeon  or  general  practitioner  can 
do.  An  attempt  to  do  more  is  not  generally  dictated  by  a 
desire  to  benefit  the  patient. 

Vaccinotherapy.  The  Fallopian  tubes  not  being  acces- 
sible to  local  treatment,  we  are  justified  in  using  antigon- 
ococcic  vaccines.  They  seem  to  be  useful  in  a  small  per- 
centage of  cases. 


GONORRHEA  IN  WOMEN  231 

VENEREAL  WARTS  (CONDYLOMATA 
ACUMINATA)  IN  WOMEN 

Venereal  warts  of  the  aeuminate  or  pointed  variety  about 
the  genitals  are  due  to  uncleanliness  of  any  sort,  but  their 
development  is  particularly  favored  by  gonorrheal  dis- 
charge. Whether  they  are  caused  by  a  special  micro-or- 
ganism or  are  due  simply  to  the  irritation  caused  by  the 
gonorrheal  discharge,  the  various  cocci  found  later  being 
secondary,  has  not  been  determined. 

While  venereal  warts  occur  in  men  too,  they  are  much 
more  frequent  in  women  and  in  them  they  may  attain  an 
enormous  size.  When  of  large  size  they  show  great  simi- 
larity in  appearance  to  a  cauliflower.  Their  favorite  places 
are  the  labia,  the  anus,  the  clitoris,  the  vaginal  walls  and  oc- 
casionally the  cervix.  It  is  on  the  labia  and  around  the 
anus  where  they  attain  their  largest  size.  Pregnancy 
favors  the  formation  of  condylomata  acuminata  on  account 
of  the  increased  vascularity  of  the  parts.  While  in  men 
venereal  warts  are  sometimes  dry,  they  are  generally  moist 
in  women,  and  are  awfully  ill-smelling.  The  smell  is  some- 
times sufficient  to  render  even  the  hardened  physician  sick 
at  the  stomach. 

In  spite  of  their  disagreeable  and  sometimes  formidable 
appearance  they  are  readily. amenable  to  treatment.  They 
can  be  cauterized  with  the  actual  cautery  or  carbolic,  chro- 
mic or  lactic  acid.  Either  one  of  the  three  acids  in  full 
strength  is  satisfactory.  After  the  warts  have  been  cau- 
terized either  a  compress  of  1  per  cent,  of  lactic  acid,  or  of 
5  per  cent,  salicylic  acid  in  alcohol,  may  be  applied.  An- 
other method  of  treating  them  is  spraying  them  thoroughly 


232      GONORRHEA  AND  ITS  COIMPLICATIONS 

witli  a  concentrated  solution  of  resorcin,  and  then  apply- 
ing dry  powdered  resorcin  to  every  part.  A  few  applica- 
tions of  the  resorcin  shrivels  them  up  and  they  disappear. 
Excision  of  the  mass,  with  ligation  of  the  bleeding  vessels, 
etc.,  is  in  my  opinion  contraindicated,  for  I  have  never 
found  it  necessary  to  have  recourse  to  such  strenuous  meas- 
ures. Painting  with  pure  tincture  of  iodine  or  with  20 
per  cent,  solution  of  salicylic  acid  in  alcohol  will  also  ac- 
complish the  purpose  in  many  instances. 

GONORRHEA  AND  PREGNANCY 

Pregnancy  is  of  course  no  barrier  against  gonorrheal  in- 
fection, nor  is  gonorrheal  infection  a  barrier  against  preg- 
nancy, though  it  makes  pregnancy  less  probable,  less  fre- 
quent. The  two  may  occur  at  the  same  time.  It  unfor- 
tunately happens  not  infrequently  that  within  the  first  few 
days  of  her  married  life  a  woman  will  contract  both  gonor- 
rhea and  pregnancy  (contract  pregnancy  is  not  the  proper 
and  accepted  term,  but  I  will  let  it  stand,  for  with  some 
women  to  contract  pregnancy  is  a  greater  misfortune  than 
to  contract  a  disease).  I  have  had  a  case  of  a  woman  of 
twenty-two  w^ho  both  contracted  gonorrhea  and  became  preg- 
nant during  the  wedding  night. 

The  possibility  of  gonorrhea  not  being  excluded  in  the 
most  respectable  married  woman,  it  should  be  the  duty  of 
every  physician  engaged  to  attend  a  case  of  confinement  to 
examine  the  woman  by  the  aid  of  a  speculum  to  ascertain 
whether  or  not  she  has  any  discharge,  and  should  there  be 
any,  to  make  sure  of  its  character.  This  is  necessary  both 
for  the  sake  of  the  woman,  to  prevent  any  gonorrheal  flare- 
up  in  the  puerperium,  and  for  the  sake  of  the  child  to  pre- 


GONOERHEA  IN  WOMEN  233 

vent  the  terrible  misfortune  of  ophthalmia  neonatorum  and 
possible  blindness. 

If  the  woman  is  found  to  be  suffering  with  gonorrhea, 
then  the  same  measures  are  to  be  applied  as  in  a  non- 
pregnant woman,  except  that  greater  caution  is  necessary 
in  making  cervical  applications,  etc.,  as  too  energetic 
handling  of  the  parts  may  induce  an  abortion  [though  it  is 
a  question  whether  in  a  woman  suffering  from  gonorrhea 
an  abortion  would  not  be  preferable  to  carrying  the  child  to 
term  and  subjecting  it  to  the  risk  of  gonorrheal  ophthalmia] . 

I  emphasized  the  importance  of  rest  in  the  treatment  of 
gonorrhea  in  the  female.  When  gonorrhea  is  associated 
with  pregnancy  rest  becomes  doubly  important. 

It  is  in  cases  where  gonorrhea  is  associated  with  pregnancy 
that  we  occasionally  see  the  very  worst  kind  of  condylomata 
acuminata.  This  should  be  treated  according  to  the  rules 
outlined  above. 

Gonorrhea  in  the  puerperium  may  become  a  very  danger- 
ous disease,  but  generally  only  on  account  of  the  association 
with  it  of  various  other  bacteria,  chiefly  the  streptococci. 
Douching,  ice-bag  to  the  abdomen  and  rest  in  bed  are  the 
principal  elements  of  the  treatment.  One  of  the  bad  re- 
sults of  gonorrhea  in  the  puerperium  is  that  it  interferes 
with  the  proper  involution  of  the  uterus.  This  tendency 
must  be  counteracted  by  the  oral  or  subcutaneous  adminis- 
tration of  ergot  and  pituitary  preparations. 


CHAPTER  XXXIII 

VULVO- VAGINITIS  IN  LITTLE  GIRLS 

Vulvo-vaginitis  is  a  very  common  affection  among  chil- 
dren of  the  poor,  and  in  institutions.  In  the  latter  it  used 
to  be  one  of  the  commonest  and  most  annoying  troubles  we 
had  to  deal  with,  one  little  girl  with  vulvo-vaginitis  often  in- 
fecting an  entire  ward  or  dormitory.  In  former  years  the 
dangerously  infective  character  of  vulvo-vaginitis  was  not 
known,  and  infection  was  readily  carried  by  towels,  linen, 
toilet  seats,  bed  pans,  bathtubs,  syringe  nozzles,  thermome- 
ters, the  nurse's  hands,  etc.  Now  very  great  improvement 
has  taken  place  in  this  respect,  the  disease  being  considered 
as  contagious  as  measles  and  the  greatest  care  being  taken 
in  isolating  a  vulvo-vaginitis  patient  or  pupil  from  the 
rest.  The  leading  hospitals  now  do  not  admit  a  female 
child  to  any  of  the  wards  without  a  vaginal  smear  being 
previously  taken  and  the  presence  or  absence  of  gonococci 
being  ascertained. 

ETIOLOGY    OF   VULVO-VAGINITIS 

I  have  not  entitled  this  chapter  "Gonorrheal  Vulvo- 
vaginitis" and  the  reason  for  it  will  be  soon  apparent. 
Vulvo-vaginitis  means  simply  an  inflammation  of  the  vulva 
and  vagina,  and  it  may  be  due  to  various  causes,  such  as 
uncleanliness,  decomposing  smegma,  decomposition  of  urine 

from  incontinence,  pin  worms,  trauma  from  masturbation  or 

234 


VULVO-VAGINITIS  IN  LITTLE  GIRLS        235 

attempted  rape,  etc.  Other  varieties  are  due  to  the  pneu- 
mococcus  or  the  diphtheria  bacillus.  Then  there  is  a  ca- 
tarrhal variety  which  is  very  infectious  and  in  which  the 
gonococcus  cannot  be  found. 

Nevertheless,  granting  the  variety  of  causes  of  vulvo- 
vaginitis in  children,  the  chief  cause,  the  cause  in  the  vast 
majority  of  cases,  will  be  found  to  be  the  gonococcus.  But 
here  is  the  point,  a  point  which  I  consider  of  great  impor- 
tance :  I  claim,  as  I  have  claimed  for  many  years,  that  the 
gonococcus  which  is  found  in  the  vulvo-vaginitis  of  chil- 
dren is  not  the  same  gonococcus  with  which  we  have  to  deal 
in  the  ordinary  gonorrhea  of  the  male  or  the  ordinary  gon- 
orrhea of  the  adult  female.  It  may  be  that  it  is  not  the 
gonococcus  at  all,  but  a  coccus  which  presents  the  morpho- 
logical and  cultural  characteristics  of  the  gonococcus  but 
still  possesses  an  entirely  different  virulence — or,  we  will 
say  that  it  is  the  gonococcus  but  of  a  different  strain,  which 
is  merely  begging  the  question.  I  base  my  conviction  upon 
two  facts.  If  the  gonococcus  in  vulvo-vaginitis  of  little 
girls  were  of  the  ordinary  variety  with  which  we  are  in 
the  habit  of  dealing,  the  disease  would  be  a  much  more  se- 
vere infection  than  it  is,  particularly  if  we  take  into  con- 
sideration the  delicate  mucous  membrane  of  the  vulva  and 
vagina  in  little  girls.  As  will  be  seen  in  speaking  of  the 
symptomatology,  vulvo-vaginitis  in  children  is  very  fre- 
quently an  extremely  mild  affection.  If  the  virulent  gon- 
ococcus were  the  cause,  much  more  damage,  much  more  pain, 
and  much  more  inflammation  would  be  the  result.  Sec- 
ond, when  we  do  have  to  deal  with  gonorrhea  in  a  little  girl 
caused  by  intercourse,  by  rape,  then  the  infection  is  of  a 
much  more  severe  character.     Of  course  the  rejoinder  may 


236       GONORRHEA  AND  ITS  COMPLICATIONS 

be  made  that  in  such  eases  there  is  an  additional  element, 
namely  the  trauma.  But  there  are  many  eases  in  which  no 
trauma  has  been  inflicted,  in  which  no  penetration  has  taken 
place,  where  there  has  been  merely  contact  of  the  penis 
with  the  vulva,  and  still  the  inflammation  is  of  a  much 
severer  character.  We  are  therefore  bound  to  maintain 
that  the  infective  germ  in  so-called  gonorrheal  vulvo-vagin- 
itis  in  girls  is  a  coccus  having  the  morphological  and  cul- 
tural characteristics  of  the  gonococcus  but  of  much  lower 
virulence. 

SYMPTOMATOLOGY 

Generally  speaking,  vulvo-vaginitis  in  children  is  a  mild 
infection.  A  child  may  have  it  for  several  weeks  or  months 
without  being  aware  of  it,  without  telling  anything  about 
it,  the  diagnosis  often  being  made  by  the  mother,  who  no- 
tices a  creamy  discharge  on  the  linen  or  underwear.  And 
this  is  the  principal  symptom  in  little  girls,  the  discharge, 
which  may  be  exceedingly  profuse,  bathing  the  vulva,  va- 
gina and  cervix.  By  looking  through  a  urethroscopic  tube 
or  a  small  vaginal  speculum  the  cervix  is  often  found 
bathed  in  a  pool  of  creamy  discharge.  There  is  this  great 
difference  between  gonorrheal  infection  in  little  girls  and 
adult  females,  that  while  the  adult  vagina  is  extremely  re- 
sistant to  the  gonococcus,  a  gonorrheal  vaginitis  being  one 
of  the  rarest  things  in  practice,  the  delicate  mucous  mem- 
brane of  the  child's  vagina  offers  little  resistance  to  the 
gonococcus  and  becomes  often  inflamed  and  eroded.  In 
severe  cases  there  is  a  simultaneous  infection  of  the  urethra, 
Bartholin's  glands,  the  vulva,  vagina  and  cervix,  and  the 
child  may  complain  of  burning  at  urination,  itching  and 


VULVO-VAGINITIS  IN  LITTLE  GIRLS       237 

pain  around  the  vulva  and  anus,  and  slight  pain  in  the  ab- 
domen. There  may  be  a  slight  rise  in  temperature,  up  to 
101°  F.,  and  in  some  instances  the  attack  is  sufficiently  acute 
to  give  rise  to  a  chill  and  fever.  A  mild  arthritis  may  take 
place  within  the  first  weeks  of  the  infection,  but  as  a  usual 
thing  it  comes  later  on. 

COMPLICATIONS 

Very  fortunately,  the  most  serious  complication  of  gon- 
orrhea in  the  adult  female,  namely  inflammation  of  the  Fal- 
lopian tubes  or  salpingitis,  is  so  rare  in  little  girls  as  to  be 
practically  negligible.  Of  course  it  is  possible  that  a  mild 
inflammation  of  the  Fallopian  tubes  takes  place,  sufficient 
to  occlude  the  opening  but  not  severe  enough  to  give  any 
symptoms.  This  is  possible,  but  as  these  cases  give  no  sub- 
jective or  objective  symptoms  they  cannot  be  diagnosticated. 
This  freedom  from  salpingitis  is  due  to  three  causes.  The 
complete  closure  of  the  internal  os  offers  quite  an  effectual 
barrier  to  the  passage  of  the  gonococcus ;  second,  menstrua- 
tion, which  is  an  important  factor  in  favoring  the  growth 
and  spread  of  the  gonococcus,  is  absent ;  third,  coitus,  which 
is  one  of  the  most  positive  and  most  injurious  factors  in 
causing  salpingitis — the  inflammation  often  making  itself 
apparent  almost  immediately  after  a  more  or  less  stormy 
sexual  act — is  here  also  absent.  What  is  said  about  sal- 
pingitis also  applies  to  peritonitis,  the  latter  often  being  a 
consequence  of  the  former.  In  the  very  few  cases  where  it 
does  take  place  it  is  generally  localized  and  followed  by  rapid 
recovery  unless  too  meddlesome  treatment  interferes. 

"While,  as  stated,  vulvo-vaginitis  is  a  comparatively  mild 
infection  as  far  as  its  symptomatology  is  concerned,  it  never- 


238      GONORRHEA  AND  ITS  COMPLICATIONS 

theless  has  a  disastrous  effect  on  the  child  who  is  unfortunate 
enough  to  become  a  victim  of  the  disease.-  First  of  all,  it  is 
an  extremely  long  disease.  It  usually  takes  months,  and 
these  months  may  run  into  years,  before  a  complete  cure  is 
affected.  Second,  relapses  and  exacerbations  are  quite  com- 
mon. Third,  the  treatment  is  a  disagreeable  one  for  the 
child,  and  is  occasionally  painful.  Fourth,  it  has  a  disas- 
trous effect  on  the  child's  morale;  most  parents,  though  they 
may  love  the  child  most  affectionately,  look  somewhat  as- 
kance at  it;  and  continuous  vaginal  treatment  somehow  or 
other  has  a  humiliating  effect  on  the  child,  which  begins  to 
consider  itself  as  an  outcast,  as  something  apart  from  other 
children.  Fifth,  the  child's  education  is  very  frequently 
seriously  and  permanently  interfered  with,  because  it  must 
often  be  taken  out  of  school,  whether  public  or  private,  and 
private  tutoring  is  of  course  feasible  only  for  the  few. 
Sixth,  and  this  is  a  point  not  sufficiently  appreciated  by  the 
profession  and  the  laity,  but  it  is  an  important  point  never- 
theless :  vulvo- vaginitis  in  children  has  unfortunately  a  dis- 
astrous effect  in  hastening  the  sexual  maturity  of  the  child. 
Whether  this  is  due  to  the  congestion  of  the  organs  pro- 
duced by  the  inflammation,  or  to  the  speculum  examina- 
tions, paintings,  douches,  applications,  tampons,  supposi- 
tories, etc.,  the  fact  remains  that  girls  who  suffer  from  vulvo- 
vaginitis in  childhood  become  sexually  mature  considerably 
earlier  than  normal  girls  of  the  same  class,  stratum  and 
climate,  and  their  demand  for  sexual  satisfaction  is  much 
more  insistent.  Seventh,  a  mild  vulvo-vaginitis  may  be  the 
cause  of  permanent  sterility. 


VULVO-VAGINITIS  IN  LITTLE  GIRLS        239 

PROPHYLAXIS 

It  will  therefore  be  seen  that  vulvo-vaginitis  is  a  calamity, 
and  everything  possible  should  be  done  to  guard  female 
children  from  contracting  it.  All  children  should  always 
sleep  alone.  Under  no  circumstances  should  a  child  sleep 
with  anybody  else,  be  it  a  sister,  a  mother,  a  friend,  a  gov- 
erness, or  a  servant  girl.  People  should  be  very  careful  in 
sending  their  children  to  spend  a  night  or  two  with  some 
friends.  The  friends  may  be  all  right,  but  still  a  friend 
of  the  friends  or  a  relative  of  the  friends  may  not  be.  I 
have  known  several  cases  where  the  origin  of  the  vulvo- 
vaginitis could  be  traced  to  little  girls  spending  a  week  at 
the  house  of  some  friends  where  a  boarder  or  relative  was 
infected  with  gonorrhea.  That  children  should  be  kept 
away  from  associating  or  playing  with  adults  or  other  chil- 
dren who  are  known  to  have  gonorrheal  infection  goes  with- 
out saying.  The  child's  genitals  should  be  frequently  in- 
spected by  the  mother,  and  scrupulous  cleanliness  by  fre- 
quent bathing,  sponging  with  warm  solutions  and  powder- 
ing, should  be  maintained.  The  toilet  seats  in  school  should 
receive  special  attention.  The  wooden  seat  is  a  menace  be- 
cause it  often  harbors  gonorrheal  pus  from  either  the 
female  or  male  genitalia,  and  the  only  proper  seat  is  one 
with  the  anterior  portion  cut  away,  the  so-called  U-shaped 
seat.  Such  seats  should  become  obligatory  in  all  schools, 
railway  stations,  dispensaries  and  other  public  places. 

TREATMENT 

The  treatment  of  vulvo-vaginitis  in  little  girls  is  still  in 
a  very  unsatisfactory  condition.     On  account  of  the  small- 


240       GONORRHEA  AND  ITS  COIMPLI CATIONS 

ness  and  inaccessibility  of  tlie  parts,  thoroughgoing  treat- 
ment is  frequently  impossible.  The  noli  me  tangere  super- 
stition that  the  hymen  is  something  sacred  and  must  not 
be  ruptured  under  any  circumstances  makes  the  treatment 
still  more  difficult.  Strictly  speaking,  vulvo-vaginitis 
should  be  a  hospital  disease,  but  on  account  of  the  length  of 
time  required  for  a  cure  this  is  frequently  impracticable  or 
impossible.  But  a  competent  nurse,  or  barring  that,  a  firm 
intelligent  mother,  is  a  sine  qua  non. 

The  keynote  of  the  treatment  of  the  vulvo-vaginitis  of 
children,  as  well  as  of  gonorrhea  in  adult  females,  is  gentle- 
ness. Whatever  we  do  we  must  do  no  harm,  and  certainly 
we  must  do  nothing  which  may  favor  an  extension  of  the  in- 
flammatory process  above  the  internal  os.  The  treatment 
of  vulvo-vaginitis  in  children  consists  in  cleanliness,  ir- 
rigations of  the  vaginal  canal,  instillations  and  suppositories. 

Locally,  erosions,  if  any,  must  be  touched  up  with  silver 
nitrate  or  iodine.  The  vulva  should  be  washed  several  times 
a  day,  depending  upon  the  amount  of  the  discharge,  and 
protected  with  a  gauze  pad,  over  which  a  pair  of  drawers 
or  knickerbockers  are  used  which  the  child  itself  cannot 
undo.  The  washing  of  the  vulva  may  be  done  with  plain 
soap  and  water  or  boric  acid  solution,  or  a  solution  of  alu- 
minium acetate. 

Irrigating  the  vagina  should  be  done  by  the  aid  of  a 
fountain  syringe  and  a  small  glass  nozzle.  About  a  pint  of 
a  solution  should  be  used  at  a  time,  and  the  pressure  should 
be  low.  The  best  solution  for  vaginal  injections  is  a  weak 
1-1000  lactic  acid  solution  or  a  weak  solution  of  tincture 
of  iodine  (%  to  I  teaspoonful  to  a  quart  of  water).  "We 
do  not  expect  to  destroy  all  the  germs  by  the  vaginal  in- 


YULYO-YAGINITIS  IN  LITTLE  GIRLS        241 

jections,  but  we  do  destroy  some;  and  besides,  leaving  the 
pus  in  the  parts  produces  erosions,  chafing,  and  gives  rise 
to  condylomata  acuminata.  So  even  the  mechanical  re- 
moval of  the  pus  does  good. 

Where  an  inspection  of  the  vagina  shows  erosions  (and 
no  treatment  can  be  satisfactory  unless  inspection  is  made 
by  means  of  a  small  vaginal  speculum — not  a  urethroscopic 
tube — and  strong  light)  they  must  be  touched  up  with  a  10 
per  cent,  silver  nitrate  solution  or  with  full  strength  tinc- 
ture of  iodine. 

After  thorough  douching,  it  is  well  to  instill  in  obstinate 
cases  30  to  60  minims  of  a  5  per  cent,  protargol  solution, 
or  a  2  per  cent,  silver  nitrate  solution.  As  conditions  im- 
prove the  instillations  need  only  be  repeated  once  or  twice  a 
week. 

"While  I  have  no  use  whatever  for  suppositories  and  bou- 
gies in  male  gonorrhea,  they  are  of  some  use  in  gonorrhea  in 
the  female,  and  I  often  prescribe  a  small  2  per  cent,  pro- 
targol suppository  as  follows: 

Protargol gr.  ss 

Acidi  borici gr.  v 

01.  theobromatis gr.  xxv 

M.  f.  suppos.  No.  i.  Tal.  Dos.  No.  xxx 
Sig.     One  suppository  at  night. 

From  the  use  of  kaolin  or  kaolin  and  yeast  I  have  ab- 
stained in  little  girls :  first,  because  they  are  difficult  of  in- 
troduction and  application;  second,  the  powder  forms  hard 
concretions  which  are  difficult  of  removal,  which  is  not  the 
case  with  adult  females. 


242       GONORRHEA  AND  ITS  C O:\IPLICATI0NS 

Vaccines  I  do  not  use  at  all,  for  I  have  not  found  tliem  of 
the  slightest  value.  They  frighten  the  child  and  cause  it 
unnecessary  pain  without  producing  the  slightest  beneficial 
effect.  I  am  glad  to  see  that  other  investigators  are  coming 
to  the  same  conclusion. 


CHAPTER  XXXIV 

GONORRHEAL  OPHTHALMIA  —  GONOCOCCAL 
INFECTION  OF  THE  EYE.  OPHTHALMIA 
NEONATORUM.  OPHTHALMIA  OF  THE 
NEWBORN 

I  did  not  intend  to  devote  any  space  in  this  book  to  a  dis- 
cussion of  gonorrheal  infections  of  the  eye,  for  in  my  opinion 
eye  affections  of  all  kinds,  and  particularly  those  of  any 
seriousness,  should  be  treated  by  a  specialist  and  not  by  a 
general  practitioner ;  and  in  the  large  cities  gonorrheal  in- 
flammations of  the  eye  are  immediately  referred  to  an 
ophthalmologist.  But  I  recollected  that  this  book  is  written 
for  the  general  practitioner  in  all  parts  of  the  country,  and 
there  are  thousands  of  places  where  no  specialist  is  available. 
"With  or  against  his  will,  the  general  practitioner  is  forced 
to  treat  such  cases,  and  it  is  therefore  necessary  to  include  a 
chapter  on  the  subject. 

Gonorrheal  ophthalmia  in  adults  is  generally  due  to  direct 
infection  by  the  fingers,  soiled  towels,  etc.  "While  metastatic 
infection  of  the  eye,  by  the  toxins  reaching  the  organ  through 
the  circulation,  is  not  an  impossibility,  still  such  cases  are  so 
rare  that  they  may  be  disregarded.  In  newborn  infants  the 
infection  takes  place  directly,  by  the  eyes  touching  the  cervix 
and  vaginal  canal  or  by  the  infecting  material  being  trans- 
ferred from  the  baby 's  body.  There  are  also  cases  where  the 
infection  of  the   infant's  eyes  takes  place  in  utero,  the 

243 


244       GONORRHEA  AND  ITS  CO^IPLICATIONS 

gonococcus  penetrating  the  unruptured  membranes,  or  the 
membranes  rupturing  prematurely.  In  such  cases  the  in- 
fant is  born  with  a  fully  developed  ophthalmia,  or  it  may 
even  be  bom  totally  blind.     Fortunately  such  cases  are  rare. 

Prophylaxis.  Here  if  anywhere  prophylaxis  is  infinitely 
more  important  than  cure.  I  make  it  a  rule  to  instill  in 
every  adult  gonorrheic  a  wholesome  fear  of  infecting  his 
eyes.  I  tell  him — and  her — that  carelessness  may  mean  the 
loss  of  the  eyesight,  and  I  give  them  instructions  how  to  be 
careful,  how  to  wash  their  hands  after  touching  the  genitals, 
even  ever  so  lightly  (see  Instructions  to  Patients,  in  the 
chapter  on  ''The  Treatment  of  Gonorrhea").  And  I  can 
assure  you  that  they  follow  instructions.  Nothing  people 
are  so  much  afraid  of  losing  as  their  eyesight,  except  their 
minds. 

It  is  stated,  and  the  statement  may  be  accepted  as  correct, 
that  in  civilized  ( ? )  countries  about  one-third  of  all  the 
blindness  is  due  to  ophthalmia  neonatorum.  The  horrible- 
ness  of  the  disease  therefore  requires  no  emphasis,  no  dis- 
cussion. And  its  prophylaxis  becomes  a  matter  of  the  great- 
est importance,  imposing  a  grave  responsibility  upon  eveiy 
attendant  connected  with  bringing  a  child  into  the  world.* 
The  mother  if  afflicted  with  gonorrhea  must  be  treated  with 
frequent  non-irritating  but  mildly  antiseptic  douches,  etc. 
But  even  if  the  discharge  is  apparently  purely  leueorrheal, 
treatment  should  not  be  neglected.  For  a  leueorrheal  dis- 
charge may  also  give  rise  to  infection. 

The  child  as  soon  as  delivered  must  be  given  special  atten- 

*  The  somber  subject  of  blindness  from  gonorrheal  ophthalmia  in 
the  newborn  has  been  the  theme  of  several  stories.  It  is  treated  in 
"The  Rise  of  Richard  Martindale"  in  the  author's  "Stories  of  Love 
and  Life";  also  in  LTpton  Sinclair's  "Sylvia's  Marriage." 


GONORRHEAL  OPHTHALMIA      245 

tion  with  reference  to  its  eyes.  If  we  have  known  the 
mother  before  delivery  and  are  store  that  she  is  all  right,  then 
merely  wiping  (wiping-  always  away  from  the  eyes,  and  not 
towards  them ! )  the  infant 's  eyes  with  cotton  swabs  wet  with 
boric  acid  or  saline  solution  is  sufficient ;  but  where  we  sus- 
pect or  know  that  the  mother  has  had  a  gonorrheal  discharge, 
then  besides  the  preliminary  cleansing  we  must  instill  into 
each  eye  some  gonococcocidal  solution.  Crede  may  well  be 
considered  one  of  humanity 's  great  benefactors,  for  by  his  in- 
vestigations and  teachings  he  has  saved  the  eyesight  of  thou- 
sands and  thousands  of  children.  In  cases  that  are  strongly 
suspicious  it  is  still  advisable  to  stick  to  his  original  recom- 
mendation— the  instillation  into  each  eye  of  two  drops  of  a 
2  per  cent,  solution  of  silver  nitrate. 

In  the  general  run  of  cases,  however,  a  1  per  cent,  solution 
of  silver  nitrate  (1  drop  in  each  eye)  is  sufficient.  Instead 
of  the  silver  nitrate  we  may  use  a  5  per  cent,  solution  of 
sophol  or  protargol  or  a  15  per  cent,  solution  of  argyrol. 
These  organic  silver  compounds  have  the  advantage  over 
silver  nitrate  of  being  but  slightly  irritating.  To  judge  by 
the  latest  reports,  sophol  is  the  best  of  all  silver  preparations 
both  in  the  prophylaxis  and  the  cure  of  ophthalmia  neon- 
atorum. 

Diagnosis.  The  diagnosis  of  gonorrheal  inflammation  of 
the  eye  is  not  difficult.  The  disease  starts  with  a  red  in- 
flamed conjunctiva  and  with  an  excess  of  secretion,  which 
may  be  serous  in  the  beginning  but  soon  becomes  purulent. 
The  eye  is  badly  swollen  and  glued  together.  It  is  some- 
times so  strongly  glued  together  that  it  requires  quite  some 
washing  and  manipulating  before  the  lids  can  be  separated. 
The  separation  of  the  lids  is  always  a  disagreeable,  painful 


246       GONORRHEA  AND  ITS  COMPLICATIONS 

process,  and  sometimes  there  is  so  much  pus  behind  the  glued 
lids  that  when  they  are  opened  the  pus  spurts  out.  The 
doctor,  the  nurse  or  whoever  attends  to  a  child  or  an  adult 
with  gonorrheal  ophthalmia  must  very  carefully  guard 
against  infection  by  the  pus.  The  finding  of  the  gonococcus 
in  the  pus  make  the  diagnosis  positive. 

Treatment.  The  treatment  of  gonorrheal  inflammation 
of  the  eye  must  be  exceedingly  gentle  and  at  the  same  time 
exceedingly  vigorous,  the  word  '' vigorous"  referring  to  the 
continuous,  unremitting  care  and  watchfulness. 

If  only  one  eye  is  affected  the  first  thing  to  do  is  to  pro- 
tect the  other  eye  with  a  BuUer's  shield,  which  is  simply  a 
watch-glass  held  down  over  one  eye  with  strips  of  adhesive 
plaster.  But  the  eye  must  be  watched  carefully,  and  as  soon 
as  signs  of  inflammation  in  it  appear,  as  they  unfortunately 
only  too  often  do,  the  shield  must  be  removed  and  the  eye 
treated  like  the  other  eye. 

The  treatment  consists  in  very  frequent — some  prefer  con- 
tinuous— irrigation  or  washing  of  the  eye  with  a  2  per  cent, 
solution  of  boric  acid  or  1  per  cent,  solution  of  sodium 
chloride.  The  water  should  be  warm,  of  a  temperature  be- 
tween 100  and  110,  and  poured  from  a  glass  vessel  with  a 
spout  or  from  an  irrigator  hanging  very  low.  The  force 
with  which  the  water  touches  the  eye  must  be  very  slight. 
The  washing  or  irrigation  should  be  done  every  hour  or  half- 
hour,  or  after  decided  improvement  has  set  in  every  two 
hours.  Besides  the  washings  or  irrigations,  instillations 
into  the  eye  of  a  gonococcocidal  solution  is  absolutely  neces- 
sary. A  2  per  cent,  solution  of  silver  nitrate  is  efficient, 
but  on  account  of  the  pain  it  sometimes  causes  it  is  often 
difficult  to  apply  thoroughly.     To  derive  the  full  benefit  of 


GONORRHEAL  OPHTHALMIA      247 

the  application  the  eye-lid  must  be  fully  everted  and  the 
solution  dropped  in ;  otherwise  it  touches  only  a  portion  of 
the  eye-lids  and  the  rest  is  squeezed  out.  Instead  of  silver 
nitrate  solution  we  can  use  with  great  satisfaction  a  solution 
of  sophol  5  per  cent.,  protargol  5  per  cent.,  or  argyrol  25 
per  cent.  These  instillations  are  to  be  repeated  every  two 
to  four  hours. 

Where  the  cornea  is  involved  the  instillation  of  atropine 
sulphate  or  eserine  sulphate  (2  to  3  drops  of  a  %  per  cent, 
solution)  is  necessary. 

The  treatment  with  the  irrigations  and  instillations  must 
be  continued,  though  at  rarer  intervals,  for  several  days  after 
all  signs  of  pus  have  disappeared,  because  it  is  possible  that 
the  gonococcus  may  remain  somewhere  dormant  and  by  dis- 
continuing treatment  too  soon  a  recrudescence  of  the  inflam- 
mation may  take  place. 

METASTATIC   GONORRHEAL   CONJUNCTIVITIS 

There  are  patients  who  with  each  fresh  attack  of  gonor- 
rhea get  a  conjunctivitis  of  greater  or  lesser  severity.  Of 
course  it  is  possible  that  the  conjunctivitis  is  due  to  direct 
contagion  but  that  its  mildness  is  due  to  a  very  low  grade 
inflammation,  the  inflammation  being  mild  on  account  of  a 
certain  amount  of  immunity  developed  within  the  patient, 
but  it  is  hardly  likely.  If  the  gonococcus  penetrates  into 
the  eye  it  generally  causes  a  good  deal  of  mischief.  We  are 
justified  therefore  in  assuming  that  this  conjunctivitis  is 
due  to  a  metastatic  infection,  to  the  action  of  gonotoxins 
circulating  in  the  blood  on  the  conjunctiva.  The  treatment 
consists  in  warm  or  cold  boric  acid  compresses,  and  in  the 
instillation  into  the  eye  of  a  few  drops  three  times  a  day  oi 


248       GONORRHEA  AND  ITS  COMPLICATIONS 

a  mild  zinc  sulphate  solution:  zinc  sulphate  one  or  two 
grains,  water  one  ounce.     The  following  is  a  good  formula : 

^  Zinc  sulphate  gr.  ij 

Boric  acid gr.  x 

Wine  of  opium m.   x 

Distilled  water §  1 

Sig.     Three  drops  into  the  eye  3  or  4  times  a  day. 

NOT    ALL    CASES    OF    OPHTHALMIA    NEONATORUM    DL'E    TO 
THE   GONOCOCCUS 

Before  concluding  this  chapter  I  consider  it  necessary  to 
emphasize  one  point,  namely  that  not  all  cases  of  ophthalmia 
neonatorum  are  due  to  gonorrheal  infection.  Ignorance  of 
this  point  may  lead  to  the  gratuitous  breaking  up  of  a  home. 
A  little  knowledge  is  a  dangerous  thing.  In  former  years 
women  knew  nothing  about  such  matters.  Whether  them- 
selves diseased  or  whether  their  children  lost  their  eyesight 
a  few  days  after  birth,  it  did  not  come  to  their  minds  to  con- 
nect these  things  with  their  husbands :  it  was  a  dispensation 
of  Providence,  and  that  was  all.  Now  they  have  learned 
something.  They  know  that  the  husband's  past  may  have 
something  to  do  with  their  or  their  children's  illness. 
But  they  have  gone  to  the  other  extreme  and,  like 
all  people  with  little  knowledge,  they  are  apt  to  take 
any  little  information  they  have  gathered  for  absolute. 
A  large  percentage  of  cases  of  ophthalmia  neonatorum 
is  due  to  gonorrheal  infections,  but  not  all  by  any 
means.  What  the  exact  percentage  is  cannot  be  defi- 
nitely determined.  It  is  probably  somewhere  between 
60  and  75  per  cent.,  and  the  other  25   to  40  per  cent. 


GONORKHEAL  OPHTHALMIA      249 

are  not  due  to  the  gonococcus  at  all,  but  to  infection  with 
other  germs,  chiefly  the  streptococcus.  It  is  important  that 
the  good  wife  should  know  that  when  a  child  is  bom  afflicted 
with  the  terrible  disease  of  ophthalmia  neonatorum  it  does 
not  necessarily  mean  that  her  husband  had  infected  her  with 
gonorrhea.  The  husband  may  never  have  had  gonorrhea, 
the  cause  may  lie  in  her  own  vaginal  discharge.  Only  an 
extremely  careful  and  repeated  bacteriologic  examination 
can  determine  with  absoluteness  whether  the  discharge  in  a 
case  of  ophthalmia  neonatorum  is  due  or  is  not  due  to  the 
gonococcus. 


RARE  COMPLICATIONS  OF  GONORRHEA 

Such  complications  of  gonorrhea  as  pyemia,  septicemia, 
endocarditis,  metastatic  abscesses  in  remote  parts  of  the 
body,  erythema  and  various  other  einiptions,  need  only  be 
mentioned  here.  It  is  good  that  a  physician  should  kQOw 
that  such  complications  are  possible.  They  are,  however, 
so  rare  that  he  is  not  likely  ever  to  have  an  opportunity  of 
seeing  a  case.  If  he  should  see  them,  they  are  to  be  treated 
on  general  principles,  like  any  other  pyemic  or  septicemic 
infection,  or  like  abscesses  in  general.  Vigorous  vaccine 
treatment  will  of  course  be  unavoidable  in  such  cases  even 
if  the  results  are  not  very  promising. 

The  eruptions  need  no  special  treatment,  but  it  is  well  to 
bear  them  in  mind,  so  as  not  to  mistake  them  for  a  syphilitic 
roseola  or  other  syphilitic  eruption,  and  in  treating  a  case  of 
gonorrhea  it  is  also  weU  to  bear  in  mind  that  copaiba,  cubebs 
and  even  santal-wood  oil  may  occasionally  give  rise  to  a 
severe  erythema  and  other  rashes. 


250 


CHAPTER  XXXY 

MINOR  POINTS  * 

"When  a  patient  voids  cloudy  urine  be  sure  that  the  cloudi- 
ness is  not  due  to  phosphates  before  telling  him  he  has 
cystitis.  Add  a  drop  or  two  of  nitric  acid  to  every  cloudy 
urine. 


In  examining  a  patient's  urine  voided  in  the  office  place 
the  glass  receptacle  in  front  of  a  gas  flame  or  electric  light. 
The  smallest  shreds  and  the  faintest  clouds  of  mucus  can 
thus  be  detected. 


When  a  patient  is  unable  to  void  his  urine  in  the  office, 
leave  him  alone  in  the  room,  taking  care  to  let  him  hear  the 
trickling  stream  of  a  slightly  open  water  faucet  nearby. 
With  some  patients  you  need  only  to  strike  a  certain  ''note" 
with  the  water  faucet,  and  ' '  off  they  go. ' ' 


Pain  at  the  end  of  the  penis  is  usually  referred  from  the 
prostate  or  the  neck  of  the  bladder.  Such  a  pain  occurs  in 
prostatitis,  in  stone  or  gravel. 


Urethral  caruncle  in  women  is  a  cause  of  frequency  of 

*  Taken  principally  from  the  author's  American  Journal  of  TJrol- 
^9y>  Venereal  and  Sexual  Diseases. 

251 


252       GONORRREA  AND  ITS  COMPLICATIONS 

micturition.     Do  not  forget  to  look  for  its  presence  before 
sending  your  patient  to  a  specialist  for  cystoscopy. 


Frequent  micturition  in  women  may  occur  without  any 
changes  in  the  urine  and  without  any  lesions  in  the  bladder, 
as  a  result  of  uterine  abnormalities. 


When  prescribing  injections  for  acute  gonorrhea  be  sure 
to  tell  the  patient  how  much  fluid  to  inject.  The  pain  or 
burning  sensation  of  an  injection  into  the  anterior  urethra 
depends  upon  the  amount  of  distention  of  the  acutely  in- 
flamed mucosa,  and  hence  even  plain  water  injected  forcibly 
or  in  too  large  amount  will  cause  discomfort. 


The  normal  healthy  anterior  urethra  of  an  adult  holds 
about  10  to  18  c.c.  The  inflamed  urethra  holds  comfortably 
only  8  to  10  c.c.  A  urethral  syringe  should  hold  12  c.c. 
(i.e.,  3  drams)  and  the  patient  should  inject  only  half  its 
contents  at  first,  during  an  attack  of  acute  urethritis. 


No  one  can  swear  that  a  Gram  negative  diplococcus  which 
has  all  appearances  of  Neisser's  germ  is  a  gonococcus  un- 
less the  organism  be  grown  in  cultures  by  an  expert  in 
bacteriology.  And  even  then  there  may  be  just  a  wee  bit  of 
doubt. 


A  negative  culture  test  in  a  man  who  is  about  to  marry 
does  not  insure  his  wife  against  gonorrhea  any  more  than 
does  a  negative  Wassermann  test  insure  her  or  her  child 
against  syphilitic  infection. 


MINOR  POINTS  253 

A  chronic  localized  patch  of  urethritis,  especially  in  the 
neighborhood  of  a  stricture,  will  give  a  recurrent  discharge, 
lighted  up  by  sexual  excitement  or  by  alcoholic  indulgence. 


Non-specific  urethritis  may  be  caused  by  intercourse  with 
a  woman  during  menstruation,  but  in  all  such  cases  be  sure 
to  look  for  gonococci.  If  any  were  present  in  the  uterus  or 
cervix  they  are  apt  to  come  out  of  their  lair  just  at  the  time 
of  the  periods. 


A  solution  of  argyrol  to  be  effective  must  be  perfectly 
fresh.  After  it  has  stood  six  hours  or  more  its  effect  begins 
to  grow  less  trustworthy.  This  holds  good  with  practically 
all  the  newer  silver  salts.  Dark,  well  closed  bottles  and  a 
dark  corner  are  preventives  against  decomposition. 


Always  test  the  resiliency  of  a  soft  rubber  catheter  before 
introducing  it.  If  the  rubber  warps  or  cracks  do  not  use 
the  catheter,  unless  you  wish  to  risk  having  a  piece  remain 
in  the  bladder  when  you  withdraw  the  instrument. 


If  a  soft  rubber  catheter,  especially  an  old  one  that  has 
been  boiled  often,  "gets  stuck"  in  the  grip  of  the  vesical 
sphincter  or  of  a  stricture  when  you  attempt  to  withdraw 
it,  inject  hot  water  into  the  urethra  alongside  the  catheter, 
by  means  of  a  large  piston  syringe.  The  heat  and  pressure 
of  the  water  will  loosen  the  tight  grip  on  the  catheter  and 
it  will  slip  out  easily. 


A  good  way  to  give  prolonged  urethral  injections  (lasting 
fifteen  minutes)   is  to  fill  the  urethra  with  the  solution, 


254       GONORRREA  AND  ITS  COMPLICATIONS 

allowing  the  fluid  to  be  retained  for  five  minutes ;  then  let 
the  fluid  out  and  repeat  the  injection  with  fresh  solution, 
to  be  retained  five  minutes.  The  solution  is  then  again 
allowed  to  escape  and  the  process  repeated  with  a  fresh 
portion  for  five  minutes  more.  This  method  has  the  advan- 
tage of  preventing  unduly  prolonged  strain  upon  the 
sphincter  and  thus  avoiding  possible  entrance  of  fluid  into 
the  posterior  urethra. 


By  keeping  a  urethral  injection  in  the  canal  for  fifteen 
minutes  or  longer  the  effect  on  the  gonococci  is  greatly  en- 
hanced. Injections  squirted  in  and  squirted  out  at  once 
have  very  little  effect. 


Remember  that  in  dilating  strictures  with  progressively 
increasing  sizes  of  instruments  the  safest  way  is  to  introduce 
at  each  treatment  a  sound  or  bougie  of  the  size  already  used 
at  the  previous  treatment,  and  then  only  to  replace  this 
smaller  size  by  the  next  larger  instrument.  Never  increase 
more  than  one  or  two  numbers  at  each  sitting. 


The  best  time  to  pass  sounds  and  other  urethral  dilating 
instruments  is  in  the  evening,  when  the  patient  can  go  home 
and  rest,  instead  of  continuing  to  go  about  his  daily  work. 


Never  use  a  sound  roughened  by  frequent  boiling  or  rusty 
from  neglect.  Avoid  rusting  by  wiping  sounds  dry  while 
they  are  hot. 


The  ''penetrating  action"  of  silver  salts,  which  is  so  fre- 
quently praised,  is  not  needed  in  the  posterior  urethra  as 


MINOR  POINTS  255 

much  as  in  the  anterior.  In  the  posterior  urethra  silver 
nitrate  acts  better  than  in  the  anterior,  while  in  the  latter 
the  newer  silver  salts  are  to  be  preferred,  as  being  more 
penetrating. 


A  periurethral  fistula,  or  a  paraurethral  infected  glan- 
dular pocket  will  prevent  recovery  from,  chronic  urethritis 
and  is  always  an  open  door  for  a  reinfection.  Cure  all  such 
complications  thoroughly  before  you  dismiss  your  patient 
for  better  or  for  worse. 


Urethroscopy  is  worthless  except  in  the  hands  of  a  man 
who  knows  what  he  sees  when  he  sees  it. 


Even  an  expert  can  teU  very  little  by  looking  through  a 
urethroscopic  tube  of  a  caliber  less  than  26°  F.  The  best 
results  for  anterior  urethroscopy  are  obtained  with  a  tube 
28°  F.  or  larger. 


The  success  of  Gram's  stain  depends  on  (1)  a  thin  smear 
uniformly  spread;  (2)  an  overstaining  with  a  freshly  pre- 
pared anilin  gentian  violet  solution;  (3)  a  decolorization 
which  is  not  too  prolonged  to  take  the  dye  out  of  the  Gram 
positives;  (4)  under-staining  with  a  dilute  contrast  stain. 


Do  not  hope  to  cure  a  chronic  gonorrhea  as  long  as  the 
patient  has  a  pin-point  meatus  or  a  long  tight  foreskin,  for 
these  are  the  two  great  handicaps  in  the  race  to  recovery. 


Individuals  vary  greatly  as  regards  the  temper  of  their 
urethra.     Always  acquaint  yourself  with  the  amount  of 


256      GONOREREA  AND  ITS  COMPLICATIONS 

reaction,  the  degree  of  pain  produced,  the  extent  of  dilata- 
tion permissible  in  any  individual  patient  before  using  in- 
struments boldly  in  his  urethra. 


It  is  a  patient's  inalienable  right  to  be  protected  against 
infection,  especially  venereal  infection  in  your  office.  Be 
sure  to  boil  the  tips  of  irrigators,  syringes,  etc.,  before  using 
them. 


Nervous  and  over-anxious  patients  often  demand  daily 
treatment  with  urethral  instruments  "to  hurry  the  cure." 
Do  not  be  weak  enough  to  let  them  come  oftener  than  is 
necessary  or  advisable. 


Over-treatment  is  the  curse  of  the  amateur  urologist.  Ex- 
perience teaches  that  much  harm  and  no  good  can  come 
from  too  much  local  interference  in  urologic  conditions. 


Never  neglect  internal  and  general  treatment  in  your 
venereal  cases.  Remember  that  iron,  quinine,  arsenic,  cod- 
liver  oil,  etc.,  are  made  not  only  for  the  *' medical  case," 
but  also  for  the  genito-urinary  patient. 


Patients  with  strictures  of  the  bulbous  urethra  must  re- 
port to  the  surgeon  once  or  twice  a  year  indefinitely,  for 
the  passage  of  a  full-sized  sound,  after  they  have  been  dis- 
charged as  cured.  They  are  the  men  whom  Bazy  has  aptly 
called  "the  perpetual  subscribers"  to  dilatation. 


MINOR  POINTS  257 

COMPARISON   OF   URETHRAL   SCALES 

French    English    American     French    English    American 


14 

7 

9 

25 

14 

16 

15 

7 

10 

26 

15 

17 

16 

8 

11 

27 

16 

18 

17 

9 

11 

28 

17 

19 

18 

9 

12 

29 

17 

19 

19 

10 

13 

30 

18 

20 

20 

11 

13 

31 

19 

21 

21 

12 

14 

32 

19 

21 

22 

12 

14 

33 

20 

22 

23 

13 

15 

34 

21 

23 

24 

14 

16 

THE  MATERIA  MEDICA  OF  GONORRHEAL  AND 
NON-GONORRHEAL  URETHRITIS  AND 
THEIR  COMPLICATIONS 

It  has  been  observed  that  physicians  who  were  phar- 
macists before  they  embraced  the  medical  profession  are 
usually  successful  above  the  average,  particularly  in  the 
treatment  of  diseases  in  which  drugs  play  an  essential 
role.  I  have  always  claimed  that  a  brief  course  of  phar- 
macy should  constitute  an  integral  part  of  the  medical 
curriculum.  The  physician  who  knows  his  drugs  not 
merely  from  textbooks,  but  has  a  practical  familiarity  with 
them,  knows  how  they  look,  how  they  smell,  how  they  be- 
have in  relation  to  each  other,  their  solubilities,  their  in- 
compatibilities, is  a  more  successful  practitioner  than  he 
who  is  ignorant  of  these  matters.  He  can  help  himself,  he 
knows  better  how  to  prescribe,  and  he  often  can  show  some 
originality  in  his  combinations.  Quite  the  contrary  is  the 
case  with  physicians  who  know  their  pharmacology  or  ma- 
teria medica  only  theoretically  and  have  no  idea  of  prac- 
tical materia  medica  and  pharmacy.  They  must  be  slaves 
to  the  textbook  prescription,  and  when  they  do  make  an 
attempt  at  originality  they  often  bungle  in  a  most  ludi- 
crous manner.  This  is  true  even  of  some  of  our  foremost 
urologists.  It  is  pitiful  to  see  their  unfamiliarity  with 
some  of  the  drugs  they  prescribe,  while  of  many  valuable 

258 


MATERIA  MEDICA  259 

drugs  and  combinations  they  know  not  even  the  name.  It 
is  for  this  reason  that  some  of  them  have  recourse  to  sur- 
gery or  instrumentation  where  a  simple  drug  combination 
properly  administered  would  suffice. 

I  believe  that  a  physician  should  have  a  thorough  or  at 
least  a  good  knowledge  of  the  tools  he  handles.  His  drugs 
are  his  tools,  and  I  therefore  have  incorporated  in  this  book 
a  section  dealing  with  the  drugs  used  externally  and  in- 
ternally in  the  treatment  of  gonorrhea  and  its  complica- 
tions, giving  an  idea  of  their  physical  appearance  and 
properties,  solubility,  incompatibilities,  dosage,  undesirable 
sequelae,  etc.  The  physician  need  not  read  this  section  at 
one  sitting,  but  when  he  comes  across  a  drug,  with  which 
he  is  unfamiliar,  mentioned  in  this  book,  he  should  refer 
to  it. 


CHAPTER  XXXVI 
SILVER  SALTS^INORGANIC  AND  ORGANIC. 

Argenti  Nitras.     Silver  Nitrate 

Colorless  transparent  crystals  becoming  gray  or  almost 
black  on  exposure  to  light  and  very  soluble  in  water  (in 
half  a  part,  that  is,  it  requires  only  about  half  an  ounce  of 
water  to  dissolve  an  ounce  of  silver  nitrate) .  But  the  salt 
and  its  solutions  should  be  kept  in  amber  colored  bottles 
protected  from  light.  It  is  at  once  precipitated  by  soluble 
chlorides  even  in  very  dilute  solutions,  and  is  therefore  of 
course  incompatible  with  sodium  chloride,  cocaine  hydro- 
chloride, etc.  But  we  take  advantage  of  this  property 
when  we  want  to  neutralize  an  excess  of  silver  nitrate 
which  has  been  injected  or  applied  externally. 

In  the  office  silver  nitrate  is  best  kept  in  a  10  per  cent. 
solution.  But  only  as  much  stock  solution  should  be  made 
up  as  can  be  used  up  in  2-3  weeks. 

In  the  treatment  of  urethritis  silver  nitrate  occupies  the 
first  place.  It  is  not  a  sovereign  remedy,  it  is  not  free 
from  decided  disadvantages^ — for  it  causes  pain  and  irrita- 
tion— but  if  carefully  and  judiciously  used  it  will  do  as 
much  as  any  remedy  can  do,  and  in  chronic  urethritis  it 
will  do  what  no  other  remedy  so  far  discovered  can  do. 
And  if  I  were  limited,  in  the  treatment  of  gonorrheal  ure- 
thritis to  one  single  drug,  I  would  select  silver  nitrate. 
Its  uses  are  so  numerous  and  so  varied  that  a  detailed  men- 

260 


SILVER  SALTS— INORGANIC  AND  ORGANIC      261 

tion  of  them  will  be  found  only  in  the  text ;  here  suffice  it 
to  say  that  its  varied  indication  will  be  seen  from  the  fact 
that  the  strengths  in  which  it  is  used  vary  from  1  in  20,000 
to  1  in  10 ! 

Argenti  lodidum.     Silver  Iodide 

Numerous  attempts  have  been  made  to  introduce  this 
salt  in  various  forms — concentrated  solution,  emulsion, 
tablets — in  the  treatment  of  gonorrhea,  but  as  it  does  not 
seem  to  possess  any  advantages  which  would  compensate 
for  its  disadvantages,  the  attempts  are  given  up  and  the  salt 
is  again  forgotten.  I  have  given  it  a  trial,  but  have  dis- 
carded it. 

Albargin.     Silver  Gelatose 

A  compound  of  silver  nitrate  with  gelatose  containing 
13  to  15  per  cent,  of  silver.  Coarse  brownish  yellow  pow- 
der, readily  soluble  in  water.  Incompatible  with  chlorides. 
Used  in  1-10  to  1  per  cent,  solution  for  injection.  In  the 
abortive  treatment  Blaschko  uses  solutions  as  high  as  2  per 
cent.  On  the  market  in  3  grain  (0.2  gm.)  tablets  which 
are  convenient  for  making  fresh  solutions. 

Argentamin.     Argentamin  Solution 

This  is  a  solution  prepared  by  dissolving  10  parts  each 
of  silver  nitrate  and  10  parts  of  ethylene-diamine  in  100 
parts  of  water.  It  is  a  colorless  liquid  turning  yellow  on 
exposure  to  light;  not  precipitated  by  chlorides.  Used  as 
injection  in  ^  to  1  per  cent,  solution,  as  instillation  in  1 
to  4  per  cent,  solution. 


262     GONORRHEA  AND  ITS  COMPLICATIONS 

Argonin.     Silver  Casein 

A  compound  of  silver  and  casein  containing  4.28  per 
cent,  of  silver.  Fine  whitish  powder,  readily  soluble  in 
water,  forming  an  opalescent  solution.  Clearly  soluble  in 
a  sodium  chloride  solution.  Incompatible  with  acids. 
Used  in  %  to  2  per  cent,  or  stronger  solutions. 

Argyrol.     Silver  Vitellin 

A  silver  oxide  proteid,  containing  from  20  to  25  per  cent, 
of  silver.  Black  scales,  very  hygroscopic,  freely  soluble  in 
water  and  glycerin,  insoluble  in  oils.  Leaves  a  black  stain 
on  the  skin  and  clothes ;  fresh  stains  are  readily  removed  by 
solution  of  mercuric  chloride.  Incompatible  with  acids 
and  most  salts. 

Used  in  acute  gonorrheal  urethritis  and  in  cystitis  in 
strengths  of  5  to  25  and  even  up  to  50  per  cent.  Its  anti- 
gonorrheal  properties  are  beyond  question,  but  its  value 
has  been  greatly  overrated.  As  a  rule  it  is  non-irritating, 
but  there  are  numerous  exceptions.  We  have  seen  many 
cases  aggravated  by  its  use ;  we  have  seen  it  produce  severe 
strangury  and  hemorrhage.  Keyes  states  that  he  has  seen 
two  cases  of  prostatic  abscess  due  to  its  intemperate  use. 
It  has  no  germicidal  effect  on  the  gonococci,  but  if  use  I  in 
fresh  and  not  too  strong  solutions  (no  stronger  than  5  to 
10,  and  only  exceptionally  20  per  cent.)  it  generally  has 
a  sedative  soothing  effect,  which  is  of  value  in  acute  gonor- 
rhea. Argyrol  is  worthless  in  chronic  gonorrhea  or  in  any 
form  of  non-gonorrheal  urethritis. 

Cargentos.     Colloidal  Silver  Oxide 
Contains  50  per  cent,  of  metallic  silver  in  the  form  of 


SILVER  SALTS— INORGANIC  AND  ORGANIC       263 

silver  oxide  combined  with  a  modified  casein.  Black  scales 
readily  soluble  in  water  and  glycerin;  (cargentos  does  not 
really  form  a  solution  but  a  very  fine  suspension) .  Not  pre- 
cepitated  by  soluble  chlorides.  Used  in  strengths  of  5  to  25 
per  cent,  in  acute  gonorrhea.  The  suspensions  should  be 
freshly  prepared.  Also  on  the  market  in  the  form  of  3  grn. 
(0.2  gm.)  tablets,  which  are  convenient  for  preparing  solu- 
tions extemporaneously  in  the  office ;  the  tablets  must  be 
crushed  or  powdered,  sprinkled  on  cold  water,  permitted 
to  stand  for  about  five  minutes  and  then  stirred  or  shaken 
until  perfect  suspension  results. 

Cargentos  urethral  suppositories.  Each  suppository  con- 
tains 2  grains  cargentos,  in  a  vehicle  of  glycerite  of  boro- 
glycerin  and  gelatin. 

Collargol.     Colloidal  Silver 

An  allotropic  form  of  metallic  silver,  containing  about 
85  per  cent,  of  silver,  with  a  small  percentage  of  albumin 
to  make  its  solutions  more  stable.  Readily  soluble  in 
water,  forming  a  dark  brown  solution  (or  suspension) 
which  remains  stable  for  months.  While  collargol  (and 
particularly  collargol  ointment)  has  many  uses  in  various 
infections,  gonorrhea  is  not  its  field.  I  have  given  it  a 
trial  in  a  few  cases  but  with  indefinite  results. 

Hegonon 

Hegonon  is  a  combination  of  silver  ammonium  nitrate 
with  albumose  containing  about  7  per  cent,  silver.  Light 
brown  powder  readily  soluble  in  water;  the  solution  does 
not  coagulate  albumin,  nor  is  it  precipitated  by  chlorides. 
For  irrigations  it  is  used  in  solutions  of  1  in  8000  to  1  in 


264       GONORRREA  AND  ITS  COMPLICATIONS 
2000,  and  as  an  injection  in  strengths  of  1  in  500  to  1  in  200. 

Ichthargan.     Silver  Ichthyol 

A  combination  of  ichthyol  and  silver,  stated  to  contain 
30  per  cent,  of  silver.  Brown  powder  freely  soluble  in 
water  and  glycerin.  Incompatible  with  chlorides.  As  in- 
jection in  acute  gonorrhea  used  in  strength  of  1:2500  to 
1 :500.  In  chronic  gonorrhea  in  1  to  3  per  cent,  solutions. 
I  could  never  convince  myself  of  any  advantages  of  this 
silver  compound. 

Largin 

Largin,  a  silver-protalbin  combination,  containing  11 
per  cent,  of  silver.  Gray  powder,  soluble  in  10  parts  of 
water.  Used  in  gonorrhea  in  %  to  2  per  cent,  solutions. 
Has  little  to  recommend  it. 

Nargol.     Silver  Nucleid 

Nargol  is  a  combination  of  silver  with  yeast  nuclein, 
containing  about  10  per  cent,  of  silver.  Readily  soluble 
in  water.  The  solution  is  not  precipitated  by  sodium 
chloride,  nor  does  it  coagulate  albumin.  Not  decomposed 
by  hot  water.  Used  as  injection  in  acute  gonorrhea  in  14 
to  1  per  cent.,  in  chronic  gonorrhea  in  1  to  5  per  cent., 
strength.  Also  on  the  market  in  the  form  of  one  and  two 
per  cent,  urethral  bougies. 

Novargan.     Silver  Proteinate 

A  silver  albumin  compound  containing  10  per  cent,  of 
silver.  Yellow  powder,  soluble  in  water,  not  precipitated 
by  soluble  chlorides.  As  an  injection  in  2  to  10  per  cent. 
strength.     As  an  instillation  in  10  to  20  per  cent,  strength. 


SILVER  SALTS— INORGANIC  AND  ORGANIC      265 

In  the  latter  form  it  has  been  particularly  recommended  in 
the  abortive  treatment  of  gonorrhea. 

Omorol 

Omorol  is  an  albuminate  of  silver,  containing  10  per  cent, 
of  the  metal,  insoluble  in  water,  but  soluble  in  a  sodium 
chloride  solution.     It  has  hardly  been  used  in  gonorrhea. 

Picratol 

Picratol  is  a  compound  of  silver  and  picric  acid:  silver 
picrate,  silver  trinitrophenolate ;  contains  30  per  cent,  of 
silver.  Yellow  floccules,  soluble  in  50  parts  of  water. 
Used  in  %  to  2  per  cent,  solutions. 

Protargol.     Silver  Proteid 

A  compound  of  silver  and  albumin  containing  8.3  per 
cent,  of  silver  organically  combined.  A  light  brown  pow- 
der slowly  but  completely  soluble  in  two  parts  of  water. 
The  best  way  to  prepare  a  solution  is  to  sift  or  sprinkle 
the  required  amount  of  protargol  on  the  surface  of  required 
amount  of  cold  water  in  a  graduate,  and  let  it  stand  for 
a  few  minutes  when  solution  will  be  effected.  The  solu- 
tion is  not  precipitated  by  sodium  chloride  but  is  precipi- 
tated by  cocaine  hydrochloride;  this  however  may  be  pre- 
vented by  the  addition  of  boric  acid  solution  (dissolve  the 
cocaine  in  the  boric  acid  solution  and  then  mix  this  with 
the  protargol  solution).  No  glycerin  should  be  used  in 
making  a  solution  of  protargol  as  it  renders  the  solution  more 
irritating. 

As  an  injection  protargol  is  used  in  the  strength  of  Yioth 
to  1  per  cent. ;  as  instillation  in  the  strength  of  1  to  10 


266      GONORRHEA  AND  ITS  COMPLICATIONS 

per  cent,  and  as  an  irrigation  1-50  to  %  per  cent.  (1:5000 
to  1:200).  Protargol  is  one  of  our  most  valuable  organic 
silver  salts,  and  is  so  far  the  best  substitute  we  have  for 
silver  nitrate.  Unfortunately  it  is  rather  irritating  in 
strong  solutions,  being  in  susceptible  individuals  as  irritat- 
ing as  silver  nitrate  itself.  But  if  we  adjust  the  strength 
to  the  acuteness  of  the  symptoms,  we  can  avoid  too  much 
irritation.  Its  field  is  acute  and  subacute  gonorrhea.  In 
chronic  urethritis,  gonorrheal  or  non-gonorrheal,  it  cannot 
take  the  place  of  silver  nitrate.  No  other  drug  or  chemi- 
cal can. 

Silvol 

A  new  silver  proteid  compound,  containing  20  per  cent, 
of  metallic  silver.  Claimed  to  be  actively  germicidal  and 
may  be  used  in  25  per  cent,  solutions.  On  the  market  in 
1  oz.  bottles  and  in  6  gr.  capsules  in  bottles  of  50  capsules. 
The  capsules  are  convenient  to  make  extemporaneous  solu- 
tions. 

Sophol 

A  combination  of  silver  with  methylennucleinic  acid 
containing  20  per  cent,  of  silver.  Yellowish  powder,  read- 
ily soluble  in  water.  Used  principally  in  the  prophylaxis 
of  ophthalmia  neonatorum,  in  5  per  cent,  solution.  Non- 
irritating.  Have  used  it  a  few  times  in  gonorrhea  in  2  per 
cent,  solution,  but  am  unable  to  make  definite  statements 
as  to  its  value  in  comparison  with  other  silver  salts.  Solu- 
tions should  always  be  freshly  prepared  with  cold  water. 


CHAPTER  XXXVII 

MISCELLANEOUS  ANTISEPTICS  AND 
ASTRINGENTS 

Potassii  Permanganas.     Potassium  Permanganate 

KMn04 

Dark  purple  prisms  or  crytals.  Soluble  in  16  parts  of 
water,  decomposed  by  alcohol,  glycerin  and  most  organic 
substances,  and  is  therefore  preferably  used  by  itself.  The 
statement  may  sound  strange  to  some,  but  potassium  per- 
manganate is  not  used  by  me  very  frequently.  As  an  in- 
jection of  proper  concentration  (1:1000,  or  1:500)  it  is  too 
irritating.  Its  real  value  is  in  weak  solutions,  1 :3000  to 
1 :  10000,  and  in  large  quantities  as  an  irrigation.  But  as 
I  do  not  use  irrigations  in  the  routine  treatment  of  gon- 
orrhea, I  do  not  often  have  occasion  to  use  potassium  per- 
manganate. 

The  few  drugs  which  I  use  in  the  local  treatment  of  gon- 
orrhea are  the  following  in  the  order  named:  (1)  An 
organic  silver  salt  (protargol  +  argyrol),  for  acute  gon- 
orrhea, (2)  silver  nitrate  for  chronic  gonorrhea,  (3)  po- 
tassium permanganate,  as  a  change  and  in  non-gonorrheal 
urethritis,  (4)  zinc  sulphate  or  lead  acetate,  (5)  diluted 
tincture  of  iodine. 

Chinosol 

Chinosol  is  chemically  oxyquinolin  sulphate.  A  yellow 
crystalline  powder  of  a  peculiar  aromatic  odor  and  burning 

267 


268      GONORRHEA  AND  ITS  COMPLICATIONS 

taste;  very  soluble  in  water,  the  solution  having  an  acid 
reaction.  This  is  a  powerful  antiseptic,  stronger  than  mer- 
curic chloride  and  much  stronger  than  carbolic  acid.  It 
exerts  an  antiseptic  action  even  in  solutions  of  1  in  5000. 
Nevertheless  it  is  absolutely  non-toxic,  which  renders  it 
very  valuable  in  washing  the  bladder  and  irrigating  the 
urethra.  The  strength  of  the  solutions  may  vary  from  1 
in  5000  to  1  in  1000.  It  has  also  a  decided  analgesic  action, 
and  in  solutions  of  1  in  8000  to  1  in  5000  may  be  used  even 
in  hyperacute  (non-gonorrheal)  urethritis. 

Thallini  Sulphas.     Thalline  Sulphate 

Thalline  sulphate  is  chemically  tetrahydroparamethyl- 
oxyquinoline  sulphate  (thalline  has  nothing  to  do  with 
the  element  thallium).  White  powder  soluble  in  water 
and  in  oil.  Used  in  acute  gonorrhea  in  1  to  2  per  cent, 
aqueous  solutions,  or  in  chronic  gonorrhea  in  5  per  cent. 
oily  solutions.  This  drug  is  Casper's  favorite,  and  I  gave 
it  a  pretty  thorough  trial,  and  while  it  is  undoubtedly  a 
useful  agent,  it  has  no  special  merits  to  entitle  it  to  be  used 
in  the  routine  treatment  of  gonorrhea.  It  turns  brown  on 
exposure,  and  it  and  its  solutions  should  therefore  be  kept 
in  amber-colored  bottles  protected  from  light. 

Ichthyol.     Ammonium  Ichthyol-sulphonate 

Obtained  by  the  distillation  of  a  bituminous  shale  found  in 
Tyrol.  A  reddish  brown  thick  sj^rupy  liquid,  peculiar  odor 
and  taste.  Is  not  used  much  in  gonorrhea,  but  it  does  occa- 
sionally give  good  results  in  obstinate  gleet,  in  the  form  of 
a  2  per  cent,  injection. 


ANTISEPTICS  AND  ASTRINGENTS  269 

Hydrargyri  Oxycyanidum.     Mercury  Oxycyanide 

Mercuric  oxycyanide.  HgO.  HgCNs.  A  white  crystal- 
line powder  soluble  in  hot  water.  Claimed  to  be  six  times 
more  active  as  a  germicide  than  mercuric  chloride.  Used 
as  a  general  antiseptic,  as  a  preservative  in  lubricants, 
and  to  wash  out  bladder — for  the  latter  purpose  in  1  in  5000 
to  1  in  3000  strength. 

Alumen.     Alum.     Aluminium  and  Potassium  Sulphate 

White  powder,  soluble  in  water  and  in  glycerin.  A  pure 
astringent,  used  occasionally  in  chronic  gonorrheal  and  in 
non-gonorrheal  urethritis,  in  1  to  5  per  cent,  strength.  It 
is  seldom  prescribed  alone,  usually  as  one  of  the  ingredients 
in  astringent  injections.  Often  prescribed  with  lead  ace- 
tate (see  lead  ac'etate),  when  it  produces  a  double  decom- 
position with  the  formation  of  aluminium  and  potassium 
acetate  (in  solution)  and  lead  sulphate  (in  precipitation), 
according  to  the  following  reaction : 

Al,  K,(S0J,-f4  Pb(C,H30,),  =  2  A1(C,H30,)3  + 
2  KC2H3O2  +  4  PbSO^. 

I^     Plumbi  Acetatis,  gr.  viij 
Aluminis,  gr.  viij 
Aquae,  §  iv 

Sig.     Shake  well. 

A  dram  of  powdered  acacia  may  be  added  to  the  above 
prescription  to  keep  the  lead  sulphate  better  in  suspension. 

Cupri  Sulphas.     Copper  Sulphate 

Large  deep  blue  crystals.  Very  soluble  in  water  and 
in  glycerin.     Powerful  astringent.     Seldom  used  in  gon- 


270      GONORRHEA  AND  ITS  COMPLICATIONS 

orrhea  of  the  male,  thougli  occasionally  it  renders  excellent 
service  in  chronic,  dragging  cases.  It  is  then  used  as  an 
injection,  ^/^^  to  1  per  cent,  strength  (%  gr.  to  5  grains 
to  the  ounce), or  as  an  instillation,  1  to  10  per  cent,  strength, 
2  to  3  drops.  The  solution  may  be  made  with  water  alone, 
or  with  water  and  glycerin.  For  instillation,  I  use  a  5  or 
10  per  cent,  solution  in  pure  glycerin  (no  water  at  all  be- 
ing employed)  ;  the  crystals  are  crushed,  put  into  the  gly- 
cerin, and  the  bottle  is  placed  in  a  dish  with  warm  water, 
and  shaken  occasionally  until  dissolved.  In  female  gon- 
orrhea, it  is  used  with  good  results,  combining  cheapness 
with  good  astringent  and  bactericidal  properties.  In  the 
division  of  the  Vienna  General  Hospital,  where  th?,  prosti- 
tutes are  treated,  gallons  and  gallons  of  copper  sulphate 
solution  are  used  daily. 

Plumbi  Acetas.     Lead  Acetate.     Sugar  of  Lead 

Colorless  crystals  or  whitish  powder,  very  soluble  in  water 
and  in  glycerin.  Efflorescent  and  readily  attracts  car- 
bon dioxide  from  the  air,  becoming  converted  into  lead  car- 
bonate. Should  therefore  be  kept  in  well  stoppered  bottles. 
Pure  astringent,  used  in  strength  of  ^  to  2  per  cent.  (1  to 
10  grains  to  the  ounce  of  water).  Is  frequently  prescribed 
in  combination  with  zinc  sulphate,  when  a  chemical  decom- 
position takes  place,  zinc  acetate  being  formed  and  remain- 
ing in  solution,  and  lead  sulphate  precipitating.  The  reac- 
tion is  as  follows : 

ZnSO^  -f  Vh{C^IL^O^)^  =  Zn(Q^n^O^)^  +  PbSO^. 

To  be  properly  prepared,  the  zinc  sulphate  and  the  lead 
acetate  are  to  be  dissolved  separately  each  in  about  half  of 


ANTISEPTICS  AND  ASTRINGENTS  271 

the  water  prescribed,  then  one  solution  is  to  be  added 
slowly  and  in  small  portions  to  the  other,  shaking  after  each 
addition.  Prepared  this  way  the  lead  sulphate  is  in  very 
fine  subdivision,  and  not  in  lumps,  and  when  injected  it 
does  not  irritate  the  urethra,  but  leaves  a  fine  coating  over 
it,  which  produces  a  prolonged  astringent  and  healing  ac- 
tion.   A  good  formula  is  the  following: 

Zinci  sulphatis,  gr.  xij 
Plumbi  acetatis,  gr.  xij 
Hydrastis  aquos.,  fl.  §  ss 
Acaciae  pulv.,  3  iss 
Aquae  q.  s.  ad.  §  iv 
S.     Shake  well. 

Zinci  Acetas.     Zinc  Acetate 

Soft  white  crystals  of  a  pearly  luster.  Very  soluble  in 
water  (in  about  21^  parts).  Purely  astringent.  Used  as 
a  urethral  injection  in  strengths  of  %  to  3  per  cent.  Often 
less  irritating  than  zinc  sulphate. 

Zinc  chloride  and  zinc  iodide  are  merely  mentioned  to  be 
condemned.    They  have  no  field  in  any  form  of  urethritis. 

Zinci  Sulphas.     Zinc  Sulphate 

Colorless  crystals  or  a  crystalline  powder,  very  soluble 
in  water  (about  half  a  part)  and  in  glycerin  (3  parts). 
Its  field  is  in  the  terminal  stages  of  gonorrhea,  though  by 
its  astringent  action  it  sometimes  does  good  service  in  the 
first  stage  also,  when  the  discharge  is  very  profuse,  and 
the  other  symptoms  not  very  acute.  Used  as  an  injection 
in  strength  of  %  to  3  per  cent.    In  the  office  best  kept  as  a 


272       GONORRHEA  AND  ITS  COMPLICATIONS 

10  per  cent,  solution,  with,  a  little  boric  acid  to  prevent 
fungous  growths. 

Of  late,  I  have  been  in  the  habit  of  adding  a  little  zinc 
sulphate  to  my  silver  nitrate  injections  and  instillations. 
While  not  interfering  with  the  specific  action  of  the  silver,  it 
does  counteract  the  tendency  of  the  latter  to  cause  or  in- 
crease discharge. 

Zinci  Permanganas.     Zinc  Permanganate 

Violet  brown  crystals,  very  hygroscopic,  very  soluble  in 
water.  As  an  injection  %o  to  %  per  cent  solution  (II/2  to 
2%  grains  to  the  ounce) .  Sometimes  very  serviceable  in  old 
gleety  conditions.  Should  not  be  rubbed  or  brought  in  con- 
tact with  organic  substances  (like  glycerin)  or  explosion 
may  occur. 

Nizin 

Nizin  is  chemically  zinc  sulphanilate.  On  the  market  in 
the  form  of  2  grain  tablets,  of  which  one  to  three  to  the 
ounce  of  water  is  used  as  a  urethral  injection. 


CHAPTER  XXXVIII 
VEGETABLE  ASTRINGENTS 

Numerous  vegetable  astringents  have  been  used  in  the 
treatment  of  gonorrhea  within  the  last  century  or  two.  To 
enumerate  them  would  mean  to  enumerate  all  drugs  con- 
taining an  astringent  principle,  such  as  nutgalls,  oakbark, 
catechu,  krameria,  matico,  tannic  acid,  gallic  acid,  etc.,  etc. 
They  have  all  fallen  practically  into  disuse,  because  they  are 
not  uniform  in  their  composition,  uncertain  and  unreliable 
in  their  action,  possess  no  antiseptic  properties  and  cannot 
be  made  sterile.  For  these  reasons  they  have  very  prop- 
erly been  discarded.  The  only  vegetable  drug  that  is  still 
used  rather  frequently  in  urethral  injections,  is  hydrastis, 
and  this  drug  is  not  used  on  account  of  its  purely  astringent 
action,  but  it  is  supposed  to  exert  a  specific  action  in  con- 
trolling the  hyperemia  of  the  urethral  canal.  It  is  not  on 
account  of  its  tannic  acid  that  we  use  it,  but  on  account  of 
its  valuable  alkaloids  hydrastine,  and  to  a  lesser  extent  ber- 
berine.  Formulas  containing  hydrastis  will  be  found  in  the 
Formulary,  at  the  end  of  the  volume. 

Lloyd's  aqueous  hydrastis  is  used  considerably,  and  a  so- 
lution of  the  alkaloids  hydrastine  and  hydrastinine  gives 
good  results  occasionally. 


273 


CHAPTER  XXXIX 
LOCAL  ANESTHETICS 

Cocaine  Hydrochloride 

Cocaine  is  the  chief  alkaloid  of  coca  leaves.  Medicinally 
it  is  used  principally  in  the  form  of  the  hydrochloride.  It 
is  in  the  form  of  small  or  large  colorless  crystals,  granular 
or  fine  white  powder.  It  is  exceedingly  soluble  in  water 
(less  than  half  a  part,  that  is  10  grains  of  the  salts  require 
only  4  drops  or  minims  of  water  for  complete  solution). 
It  was  the  first  local  anesthetic  discovered  (by  Dr.  Carl 
KoUer,  in  1884),  and  it  still  remains  our  surest,  promptest 
and  longest  lasting  agent  for  producing  local  anesthesia. 
It  also  has  the  great  advantage  of  contracting  the  blood 
vessels  of  the  part  to  which  it  is  applied,  producing  a  local 
ischemia,  thus  rendering  operations  more  or  less  bloodless. 
It  would  be  the  ideal  local  anesthetic,  but  for  one  thing: 
it  is  very  toxic,  unexpected  dangerous  by-effects,  collapse, 
etc.,  are  produced  by  its  use,  and  it  has  been  responsible 
for  a  number  of  deaths.  Its  toxicity  has  led  the  world's 
great  chemists  to  invent  synthetic  substitutes,  and  they  have 
been  quite  successful.  Several  are  now  in  general  use, 
but  for  genito-urinary  manipulations  only  three  come  under 
consideration.  They  are :  Alypin,  beta-eucain  and  novo- 
caine. 

Alypin.     Alypin  Hydrochloride 

Alypin  is  chemically  the  hydrochloride  of  benzoyl  tetra- 
methyl    (diamino)    ethylisopropyl  alcohol.    It  is  a  white 

274 


LOCAL  ANESTHETICS  275 

crystalline  powder  readily  soluble  in  water,  and  quickly  ab- 
sorbed by  mucous  membranes.  It  is  one  of  the  best,  if  not 
on  the  whole  the  best,  local  anesthetic  in  genito-urinary 
diseases,  because  it  is  practically  equal  in  its  effects  to  co- 
caine, but  is  much  less  toxic.  Used  in  same  strength  as 
cocaine,  generally  2  to  4  per  cent,  solutions.  As  it  pro- 
duces a  transient  hyperemia,  it  is  best,  in  cutting  operations, 
to  combine  it  with  suprarenal  preparations.  Alypin  may 
be  sterilized  by  boiling,  but  it  is  best  to  proceed  as  follows : 
First  boil  the  water  thoroughly,  say  in  a  test  tube,  then  add 
the  alypin,  and  continue  the  boiling  for  another  minute  over 
a  small  flame. 

Alypin  nitrate.  As  alypin,  which  is  a  hydrochloride, 
is  incompatible  with  silver  nitrate,  we  must  use  a  nitrate 
whenever  we  wish  to  combine  alypin  with  silver  nitrate,  or 
when  we  wish  to  anesthetize  the  urethra  prior  to  the  use  of 
silver  nitrate.  The  properties  of  alypin  nitrate  are  practi- 
cally the  same  as  those  of  alypin. 

Eucaine.     Beta-eucaine 

This  synthetic  local  anesthetic  is  on  the  market  in  two 
forms,  the  hydrochloride  and  the  lactate.  Chemically  eu- 
caine is  trimethylbenzoxypiperidin.  The  hydrochloride  is 
a  white  powder,  soluble  in  about  25  parts  of  water, 
producing  a  neutral  solution,  which  can  be  boiled  without 
decomposition.  As  a  local  anesthetic  it  is  weaker,  but  less 
toxic  than  cocaine,  nor  does  it  produce  the  ischemia  which 
the  latter  does.    May  be  used  in  2  to  4  per  cent,  solutions. 

Beta-Eucaine  Lactate.  Properties  the  same  as  of  the 
hydrochloride,  but  is  more  soluble  in  water. 


276       GONORRHEA  AND  ITS  COMPLICATIONS 

Novocaine.     Novocaine  Hydrochloride 

Novocaine  is  chemically  the  hydrochloride  of  para-amino- 
benzoyldiethylaminoethanol.  Small  colorless  crystals,  very 
soluble  in  water  (1  part),  and  the  solution  may  be  heated 
to  boiling  without  decomposition.  An  efficient  local  anes- 
thetic, but  much  less  toxic  than  cocaine.  For  anesthesia 
in  the  urethra  1  to  4  per  cent,  solution  may  be  used.  Its 
effect  is  more  satisfactory  if  combined  with  a  few  drops  of 
epinephrin  or  adrenalin  solution.  There  are  on  the  market 
tablets  containing  both  novocaine  and  adrenalin  or  supra- 
renine. 

Novocaine  nitrate.  As  novocaine  hydrochloride  gives  a 
precipitate  with  silver  nitrate,  we  must  use  novocaine 
nitrate  whenever  we  wish  to  combine  the  two  (See  Alypin 
Nitrate). 

There  is  also  a  novocaine  base,  which  is  soluble  in  oils. 


CHAPTER  XL 

ANTIGONORRHEAL  REMEDIES  FOR  INTERNAL 

USE 

Oil  of  Santalwood,  Its  Derivatives  and  Combinations 

The  principal  remedies  used  internally  in  the  treat- 
ment of  gonorrhea  are  the  so-called  Balsamics.  They  com- 
prise (1)  oil  of  santalwood  and  its  numerous  derivatives 
and  combinations,  (2)  copaiba  and  (3)  cubebs. 

Oleum  Santali.     Santalwood  Oil.     East  Indian  Sandal- 
wood Oil.     Oil  of  White  or  Yellow  Sandalwood 

A  volatile  oil  obtained  by  distilling  the  wood  of  Santalum 
Album.  Yellowish  somewhat  thick  liquid,  with  a  peculiar 
aromatic  odor  and  disagreeable  taste.  Its  virtues  depend 
upon  its  active  principle,  santalol,  of  which  it  should  contain 
not  less  than  90  per  cent.  The  dose  is  5  to  10  minims,  pref- 
erably in  capsules,  3  or  4  times  a  day,  about  an  hour  after 
meals. 

Oil  of  santal  is  a  very  valuable  remedy  in  gonorrhea ;  un- 
fortunately we  are  frequently  disappointed  in  its  action, 
because  much  of  the  santal  oil  of  the  market  is  adulterated 
with  the  West  Indian  oil,  with  castor  oil,  oil  of  turpentine, 
etc.  Some  of  the  santal  oil  dispensed  in  drug  stores  is 
practically  worthless.  It  is  therefore  important  to  order 
the  oil  in  capsule  form,  specifying  the  brand  of  certain  re- 
liable manufacturers. 

277 


278      GONORRHEA  AND  ITS  COMPLICATIONS 

I  start  with  the  santal  oil  quite  early  in  the  disease — 
three  to  five  days  after  the  discharge  has  been  well  estab- 
lished. For  the  first  few  days  I  give  an  alkaline  anti- 
spasmodic mixture,  and  then  as  the  acute  symptoms  have 
somewhat  subsided,  I  start  in  with  santal  oil  (see  chapter 
on  the  treatment  of  acute  gonorrhea)  and  keep  it  up, 
more  or  less,  during  the  entire  course  of  the  disease.  I  find 
that  it  shortens  the  disease,  prevents  complications  and 
makes  the  local  treatment  easier  to  manage ;  that  is,  the 
injections  cause  less  irritation  than  they  do  without  the  use 
of  the  balsamics. 

Santal  wood  oil  is  a  most  valuable  drug ;  unfortunately  it 
has  two  disagreeable  by-effects.  They  do  not  manifest  them- 
selves in  all  patients,  but  they  do  in  a  considerable  pro- 
portion. These  by-effects  are:  gastric  irritation,  which 
expresses  itself  in  loss  of  appetite,  belching,  heartburn,  etc., 
and  in  irritation  of  the  kidneys,  which  shows  itself  by 
pain,  sometimes  quite  severe,  across  the  lumbar  region, 
and  by  a  slight  albuminuria.  These  disagreeable  by-effects 
led  the  manufacturing  chemists  to  improve  the  santal  wood 
oil,  by  isolating  its  active  principle,  santalol,  and  combin- 
ing it  chemically  in  such  a  manner  as  to  make  it  insoluble 
in  the  stomach;  the  preparation  splitting  up  and  being 
absorbed  in  the  intestines  only.  These  improvements 
on  santal  wood  oil  are  very  valuable,  only  they  are  more 
expensive.  Still  in  delicate  patients  and  in  patients  who, 
on  account  of  gastric  or  renal  disturbance,  cannot  tolerate 
the  pure  santal  wood  oil,  we  are  obliged  to  administer  its 
various  derivatives  and  combinations. 


INTERNAL  REMEDIES  279 

Allosan 
This  is  chemically  the  allophanic  acid  ester  of  santalol, 
containing  72  per  cent,  of  the  latter.    Doses  and  uses  same 
as  of  oil  of  sandal  wood. 

Arheol 
Arheol  is  'pure  santalol,  the  active  principle  of  oil  of 
sandalwood.    Dose :  9  to  12  capsules  daily. 

Blenal 
Blenal  is  chemically  santalol  carbonate,  or  the  carbonic 
acid  ester  of  santalol.    It  is  odorless,  tasteless,  and  claimed 
to  be   absolutely  non-irritating  to  stomach  or  intestines. 
Dose :  15  drops  3  times  a  day,  on  sugar  or  in  hot  milk. 

Carbosant 
Carbosant  is  santalol  carbonate,   the   same   as  Blenal, 
which  see. 

Gonosan.  Gonosan  Capsules.  Kava-Santal 
Gonosan  is  a  solution  of  the  resins  of  kava-kava  in  pure 
sandalwood  oil.  On  the  market  in  the  form  of  capsules 
only,  the  dose  of  which  is  one  to  two  capsules  three  to  four 
times  a  day.  It  is  one  of  the  most  valuable  combinations 
we  have  in  the  internal  treatment  of  gonorrhea,  because  the 
kava-kava  has  a  distinct  analgesic  effect,  and  the  combina- 
tion as  a  rule  promptly  subdues  the  pain  of  urination, 
strangury,  etc.  It  also  seems  to  reduce  the  secretion  more 
promptly  than  sandalwood  oil  alone. 

Santyl.     Santalol  Salicylate 
Santyl  is  chemically  salicylate  of  santalyl.     It  contains 
approximately  60  per  cent,  of  santalol  and  40  per  cent,  of 


280       GONORRHEA  AND  ITS  COIMPLICATIONS 

salicylic  acid.  Yellowish  oily  liquid  with  slight  odor  and 
taste.  Passes  the  stomach  for  the  most  part  unchanged, 
splitting  up  into  its  two  constituents  in  the  intestines.  It 
is  remarkably  free  from  any  irritating  effects  on  the  stomach 
and  kidneys,  though  occasionally  we  of  course  meet  a  man 
or  a  woman  who  complains  of  eructations.  It  is  very  rare 
however  to  find  a  patient  in  whom  it  causes  even  transient 
albuminuria  or  pain  across  the  kidneys  unless  it  is  given  in 
very  large  doses.  On  the  market  in  liquid  form  and  in 
capsules,  containing  8  minims  (0.5)  each.  Dose,  2  cap- 
sules 4  times  a  day  or  3  capsules  3  times  a  day. 

Thyresol 

Thyresol  is  chemically  the  methyl  ether  of  santalol.  It  is 
a  colorless  liquid,  of  an  aromatic  odor,  insoluble  in  water, 
and  it  is  claimed  to  pass  the  stomach  unchanged,  liberating 
the  santalol  only  in  the  intestines,  thus  saving  the  patient 
from  eructations  and  other  gastric  disturbances.  On  the 
market  in  liquid  form,  in  5  grain  capsules  and  in  5  grain 
tablets  (prepared  with  magnesium  carbonate).  Dose:  two 
capsules  or  tablets  3  or  4  times  a  day. 

Copaiba 

This  popular  remedy  incorrectly  referred  to  as  Balsam 
of  Copaiba  is  an  oleoresin  (that  is,  it  consists  of  an  oil  and 
a  resin)  obtained  from  several  South  American  species  of 
copaiba.  It  is  a  thick  viscid  liquid,  yellow  to  brownish 
yellow  in  color,  having  a  peculiar,  rather  disagreeable 
aromatic  odor  and  a  disagreeable  acrid  taste.  Insoluble  in 
water,  but  soluble  in  fixed  and  volatile  oils.  This  is  one  of 
the  best  known  and  most  popular  antigonorrheics,  but  also 


INTERNAL  REMEDIES  281 

one  of  the  nastiest  and  most  nauseating.  But  few  people 
can  stand  it  without  having  their  stomach  upset  or  their 
kidneys  irritated.  It  is  well  to  bear  in  mind  that  if  nitric 
acid  be  added  to  the  urine  of  a  person  taking  copaiba,  a 
precipitate  will  be  formed,  which  may  make  the  unwary 
physician  believe  that  the  patient  has  albumen  in  his  urine. 

The  dose  of  copaiba  is  10  to  30  min.  3  to  4  times  a  day.  If 
given  at  all  it  should  be  given  in  capsules.  To  give  it  on 
sugar,  in  water  or  even  in  emulsion  is  to  inflict  unnecessary 
cruelty  on  the  patient. 

It  is  the  chief  ingredient  in  the  famous  (or  infamous) 
Lafayette  mixture  (mistura  copaiba,  Lafayette,  N.  F.), 
which  consists  of  copaiba,  spirit  of  nitrous  ether,  compound 
tincture  of  lavender,  solution  of  potassium  hydroxide,  syrup 
and  mucilage  of  acacia.  (For  complete  formula  see  For- 
mulary.) 

Oleum  Copaibae 

Copaiba  can  be  separated  into  the  two  constituents:  an 
oil  and  a  resin.  The  resin  is  almost  inert  and  is  no  longer 
official.  The  oil  is  official,  and  may  be  given  in  doses  of  10 
to  30  minims. 

Cubeba 

Cubeb  is  the  fruit  (unripe  but  full  grown)  of  Piper 
Cubeba.  It  is  occasionally  used  in  substance,  in  the  form 
of  powder,  but  more  commonly  in  the  form  of  one  of  its 
derivatives,  the  oleoresin  or  the  oil.  The  fluid  extract  is 
not  a  good  preparation,  because  it  contains  alcohol,  and  we 
do  not  wish  to  give  alcohol  in  gonorrhea.  The  dose  of  pow- 
dered cubebs  is  10  to  60  grains  in  capsule,  cachet  or  paste 


282      GONORRHEA  AND  ITS  COMPLICATIONS 

form;  the  dose  of  the  oleoresin  is  10  to  20  minims;  of  the 
oil  10  to  30  minims.  If  at  all  administered,  it  should  be 
given  only  after  the  acute  inflammatory  symptoms  have 
subsided. 

Copaiba  and  cubebs  are  seldom  prescribed  by  venereal 
specialists,  and  still  more  seldom  prescribed  alone.  As  a 
rule  we  give  a  combination,  in  capsule  form,  of  copaiba, 
oleoresin  of  cubeb  and  oil  of  sandalwood.  A  small  quan- 
tity of  some  pleasant  volatile  oil,  such  as  oil  of  cinnamon  or 
cardamom  is  also  added  to  make  the  combination  less  unac- 
ceptable to  the  stomach.  If  we  could  have  capsules  insol- 
uble in  the  stomach,  but  soluble  in  the  duodenum,  quite  an 
advance  would  be  made  in  the  treatment  of  our  gonorrheal 
patients.  So  many  stomachs  would  be  saved  from  unnec- 
essary torture.  But  unfortunately  we  are  still  far  from 
possessing  a  really  stomach-insoluble  but  intestine-soluble 
capsule. 

Arhovin 

A  compound  or  mixture  of  diphenylamine,  thymol  ben- 
zoate  and  ethyl  benzoate.  Offered  as  a  substitute  for  the 
santal  oil  preparations.  Generally  prescribed  in  capsules 
of  4  minims  each — one  to  two  capsules  three  to  six  times 
a  day. 


CHAPTER  XLI 
URINARY  ANTISEPTICS 

Hexamethylenamine 

This  product  is  obtained  by  the  action  of  ammonia  on 
formaldehyde.  Chemically  it  is  hexamethylene  tetramine 
(CH2)6N4,  and  is  known  to  commerce  under  a  great  vari- 
ety of  trade  names.  Urotropin,  under  which  name  it  was 
originally  introduced  to  the  medical  profession,  is  sup- 
posed to  be  the  purest  brand;  other  names  by  which  it 
is  known  are:  formin,  cystogen,  aminoform,  uritone,  etc. 
On  excretion  from  the  kidneys,  it  decomposes  with  the 
liberation  of  a  small  percentage  of  formaldehyde,  but  it 
does  this  only  in  acid  urine.  When  administering  hexa- 
methylenamine we  must  therefore  make  sure  that  the  urine 
is  acid;  and  if  it  is  not,  we  must  render  it  acid  by  the 
administration  of  monosodic  acid  phosphate  or  similar  sub- 
stances. While  the  action  of  hexamethylenamine  in  clear- 
ing up  a  bacterial  urine,  in  cystitis,  pyelitis,  etc.,  is  un- 
questionable, it  is  of  no  value  in  gonorrhea,  and  its  admin- 
istration without  any  definite  indication  is  not  only  use- 
less, but  often  proves  injurious  by  its  irritating  effect  on 
the  neck  of  the  bladder.  There  is  no  question  that  some 
brands  of  hexamethylenamine  on  the  market  are  more  irrir 
tating  than  others,  and  if  given  in  large  doses,  not  properly 
diluted,  hematuria  may  result. 

283 


284      GONORRHEA  AND  ITS  COMPLICATIONS 

The  dose  of  hexametliylenamine  is  5  to  15  grains  dis- 
solved in  8  to  12  ounces  of  water  3  to  4  times  a  day.  Un- 
fortunately some  doctors  are  careless  in  this  respect,  and 
we  have  seen  i^atients  with  gastro-intestinal,  renal  and 
vesical  irritation  from  swallowing  the  tablets  whole,  with- 
out previous  solution  in  water. 

The  best  way  is  to  order  5  or  7%  grains  of  hexamethy- 
lenamine  with  10  grain  tablets  of  monosodic  acid  phosphate 
and  order  one  tablet  of  the  former  with  one  or  two  tablets 
of  the  latter  to  be  dissolved  in  a  large  glass  of  water.  Tab- 
lets are  now  manufactured  containing  both  chemicals. 

I  wish  to  emphasize  that  in  uncomplicated  gonorrhea 
hexamethylenamine  has  no  place.  Wherever  any  instru- 
mentation becomes  necessary,  such  as  irrigating  the  bladder, 
passing  a  sound,  etc.,  then  it  becomes  invaluable  in  pre- 
venting infection.  In  such  cases  it  is  advisable  to  have 
the  patient  take  a  dose  when  he  leaves  for  the  office,  and 
another  dose  when  he  gets  home. 

Amphotropin 

This  recent  addition  to  the  list  of  urinary  antiseptics  is 
chemically  Hexamethylenamin  Camphorate.  It  is  a  white 
crystalline  powder  soluble  in  about  10  parts  of  water.  It 
renders  alkaline  urine  acid,  and  has  a  diuretic  action. 
Claimed  to  be  specially  indicated  in  bacteriuria,  chronic 
cystitis  and  pyelitis.  Contraindicated  in  acute  cystitis  and 
urethritis.  Dose  7%  to  15  grains  (one  to  two  tablets) 
3  times  a  day,  dissolved  in  water. 

Aminoform 
This  is  a  trade  name  for  hexamethylenamine. 


URINARY  ANTISEPTICS  285 

Borovertin 

Borovertin  is  chemically  hexamethylenamin  borate,  con- 
sisting of  about  equal  parts  of  hexam.  and  boric  acid. 
White  powder  soluble  in  11-12  parts  of  water.  Dose  8  to 
15  grs.  3  times  a  day. 

Cystogen 
This  is  a  trade  name  for  hexamethylenamine,  which  see. 

Helmitol 

Helmitol  is  chemically  hexamethylenamin-anhydro- 
methylencitrate.  "White  powder,  slight  acid  taste,  soluble 
in  10  parts  of  water.  Same  action  as  hexamethylenamin, 
but  it  is  claimed  that  it  is  active  in  alkaline  as  well  as  in 
acid  urine.  Dose:  5  to  15  grains  (1  to  3  tablets),  dis- 
solved in  water  3  to  4  times  a  day. 

Hexalet,  Hexal 

This  is  a  chemical  combination  of  hexamethylenetetramine 
(40  per  cent.)  and  sulphosalicylic  acid  (60  per  cent.)  It 
is  in  the  form  of  small  white  crystals  very  soluble  in  water, 
of  an  acidulous  taste.  Claimed  to  possess  decided  advan- 
tages over  hexamethylenamine.  Dose:  15  grains  dissolved 
in  a  glass  of  water  3  to  4  times  a  day. 

Urotropin 
The  purest  brand  of  hexamethylenamine  on  the  market. 

Saliformin 

Saliformin  is  hexamethylenamin  salicylate.  White 
powder,  slightly  acid  taste,  readily  soluble  in  water. 
Claimed  to  possess  the  combined  actions  of  its  two  con- 


286       GONORRHEA  AND  ITS  COMPLICATIONS 

stituents,  hexamethylenamin  and  salicylic  acid.    Dose :  5  to 
15  grains  3  to  4  times  a  day. 

Sodium  Acid  Phosphate,  Monobasic 

"When  the  urine  is  alkaline,  and  full  of  bacteria,  it  is 
often  necessary  quickly  to  acidify  it,  in  order  to  permit 
urotropin  or  hexamethylenamin  to  exert  its  action,  the  lat- 
ter drug  as  mentioned  elsewhere  not  acting  in  an  alkaline 
medium.  For  this  purpose  of  acidifying  the  urine,  one  of 
the  best  agents  is  the  recently  introduced  monosodic  acid 
phosphate.  This  is  administered  in  doses  of  15  to  30 
grains  frequently  repeated  until  the  desired  effect  is  ob- 
tained. The  ordinary  sodium  phosphate  of  the  market,  used 
as  a  cholagogue  and  laxative,  is  also  an  acid  phosphate, 
but  that  contains  two  atoms  of  sodium  and  one  atom  of 
hydrogen,  in  other  words  it  is  dibasic ;  while  this  salt  con- 
tains only  one  atom  of  sodium  and  two  atoms  of  hydrogen : 
it  is  therefore  called  monobasic  sodium  acid  phosphate, 
or  monosodic  acid  phosphate.  You  should  be  careful  in 
ordering  to  specify:  monosodic  or  monohasiCj  or  you  wiU  ^ 
surely  get  the  common  sodium  phosphate. 

Methylene  Blue 

Methylene  Blue  is  chemically  Tetramethylthionine 
hydrochloride.  It  is  one  of  the  numberless  anilin  dye- 
stuffs,  but  purified.  It  is  a  dark  green  crystalline  powder, 
very  soluble  in  water,  and  it  renders  everything  it  touches 
intensely  blue.  It  is  a  nuisance  to  handle  it,  and  is  best  1 
administered  in  the  ready  combinations,  in  pill  or  capsule  | 
form.  The  dose  is  2  to  4  grains,  with  a  small  dose  of  nut- 
meg and   extract   of  belladonna.      The   patient  must  be 


URINARY  ANTISEPTICS  287 

warned  that  his  urine  will  become  intensely  green  or  blue. 
If  not  warned,  he  may  get  frightened  out  of  his  wits  when 
noticing  his  urine  for  the  first  time,  with  the  result  that 
the  doctor  may  have  to  answer  to  a  violent  bell  or  frantic 
telephone  ring  in  the  middle  of  the  night. 

In  pure  uncomplicated  gonorrhea,  methylene  blue  seems 
to  possess  little  if  any  value.  In  cases  of  mixed  infection, 
however — and  almost  every  case  of  chronic  protracted  gon- 
orrhea becomes  sooner  or  later  one  of  mixed  infection — the 
drug  seems  to  be  a  useful  adjuvant.  In  impatient  patients, 
in  patients  of  the  nervous,  neurasthentic  stamp,  who  want  to 
see  that  something  is  being  done  for  them,  methylene  blue 
is  a  welcome  addition  to  our  other  remedies. 


CHAPTER  XLII 
LUBRICANTS 

A  lubricant  (from  Latin  luhricus,  slippery)  is  a  sub- 
stance used  to  diminish  friction  and  adliesion,  to  render 
another  substance  slippery  and  easy  of  passage.  In  pass- 
ing catheters,  bougies,  sounds,  urethroscopes,  cystoscopes, 
etc.,  we  must  use  a  lubricant,  as  otherwise  the  instrument 
would  not  pass  at  all,  or  would  pass  only  with  difficulty 
and  with  damage  to  the  mucous  membrane.  There  are 
many  formulas  for  lubricants  and  there  are  many  artificial 
water-soluble  lubricants  on  the  market,  but  even  the  best 
of  them  do  not  possess  the  same  amount  of  lubricity  that 
is  possessed  by  the  fats  and  oils,  such  as  petrolatum,  par- 
affin or  olive  oil,  for  instance.  And  in  attempting  to  pass 
a  sound  through  a  narrow,  tortuous  or  even  spasmodic 
stricture  nothing  will  answer  the  purpose  as  well  as  filling 
the  urethra  with  sterilized  olive  oil. 

Nevertheless  we  are  obliged  to  use  water-soluble  lubri- 
cants, and  for  these  reasons.  We  often  have  to  follow  our 
dilatation  by  sounds,  bougies  or  dilators  with  silver  nitrate 
solution,  or  with  a  solution  of  some  other  chemical  in  water. 
If  we  use  an  oily  or  fatty  lubricant  it  coats  the  urethra 
with  a  layer  of  oil  or  fat,  so  that  the  watery  solution  can- 
not reach  it  properly  and  exert  its  proper  effect.  Then  it 
is  much  more  difficult  to  sterilize  instruments  on  which  an 
oily  lubricant  has  been  used.     And  last,  rubber  goods  are 

288 


LUBRICANTS 


289 


injuriously  affected  by  oils  and  fats.  For  these  reasons 
substitutes  for  the  natural  lubricants  are  in  common  use, 
but  I  repeat  the  best  of  them  are  not  fully  satisfactory, 
and  personally  I  still  use  occasionally  sterilized  and  sali- 
cylated  oil  for  the  urethra  and  petrolatum  for  the  rectum. 
Glycerin  is  not  very  satisfactory,  because  it  does  not 


>  Containers  for  Lubricants 

possess  sufficient  lubricity,  in  cold  weather  it  is  thick  and 
sticks,  and  it  often  causes  burning  and  irritation  in  the 
urethra. 

The  artificial  lubricants  generally  have  chondrus  (Irish 
moss)  and  glycerin  or  tragacanth  for  a  base.  One  of  the 
best  formulas  is  the  one  originally  proposed  by  Casper.  It 
has  the  following  composition: 

Hydrargyri  oxycyanidi,  0.246 
Tragacanthae,  3.0 
Glycerini,  20.0 
Aquae  destill.  steril.,  100.0 

Some  hypersensitive  urethras  feel  some  irritation  from 
the  use  of  this  lubricant.  It  is  also  a  little  too  thick,  par- 
ticularly in  cold  weather.     I  have  therefore  modified  the 


290       GONORRHEA  AND  ITS  CO]\IPLICATIONS 

formula,  and  this  yields  me  a  more  satisfact-ory  product. 
My  modified  formula  is  as  follows: 

Hydrargyri  oxj^eyanidi,  0.2  (3  grains) 
Tragacanthae,  2.0  (30  grains) 
Glycerini,  20.0  (5  drams) 
Aquae  destill.  steriliz.,  120.0  (4  ozs.) 

Keep  well  covered  in  small,  wide  mouthed  bottles,  or 
have  it  filled  in  tin  tubes. 

Of  the  ready-made  lubricants  on  the  market,  K-Y  jelly 
is  the  best  known  and  the  one  generally  preferred.  Others 
are  lubrichondrin,  lubraseptic,  etc. 

The  ready-made  lubricants  come  in  collapsible  tin  tubes, 
a  little  being  squeezed  out  each  time  as  needed,  the  screw 
cap  being  kept  on  in  the  meantime.  This  prevents  the 
contents  from  becoming  contaminated.  The  lubricant  or- 
dered from  the  druggist  or  prepared  by  the  physician  is 
kept  in  wide-mouth,  well  corked  or  stoppered  bottles. 
Better  however  are  the  lubricant  containers  presented  in  the 
accompanying  illustrations.  The  proper  amount  of  lubri- 
cant is  easily  poured  out  when  wanted,  the  opening  in  the 
meantime  being  protected  by  corks  or  cotton  stoppers. 
One  container  can  be  used  for  the  water-soluble  lubricant, 
another  one  for  sterile  oil,  plain  or  salicylated. 

^     Ac.  salicylici,  gr.  x 
Olei  olivae,  §  ^^ 

Heat  on  a  water  bath  to  100°  C.  for  fifteen  minutes,  dis- 
solve the  salicylic  acid,  cool,  strain,  heat  again  for  five 
minutes  and  pour  in  sterilized  bottle  or  container. 


FORMULARY. 

PRESCRIPTIONS  FOR  ACUTE  AND  CHRONIC  GONORRHEA 
LAFAYETTE  MIXTURE 

^  Copaibae Sj  [30.0] 

Liq.  potassii  hydrox oij   [8.0] 

Spir.  aetheris  nitrosi §j  [30.0] 

Ext.  glyeyrrhizae Sss  [15.0] 

Syr.  acaciae giv  [120.0] 

S.    3ij — 5ss  3  times  a  day. 

This  nauseous  mixture  may  be  made  a  little  less  nauseous 
by  flavoring  it  with  a  few  drops  of  oil  of  wintergreen  or  oil 
of  cinnamon. 

MISTURA   CAPAIBAE,    LAFAYETTE,   N.   E. 

The  National  Formulary  gives  a  somewhat  different  for- 
mula for  Lafayette  mixture.     It  is  as  follows : 

1^  Copaibae §j  [30.0] 

Liq.  potassii  hydrox oij   [8.0] 

Spir.  aetheris  nitrosi §j  [30.0] 

Tine,  lavandulae  eomp §j  [30.0] 

Syrupi  (U.  S.  P.)   gijss  [75.0] 

Mucil.  acaciae  q.s.  ad gviij  [240.0] 

S.    3jj — §ss  3  times  a  day. 

291 


292      GONORRHEA  AND  ITS  COMPLICATIONS 

chapman's  copaiba  mixture 

Copaibae §j  [30.0] 

Spir.  aetheris  nitrosi §j  [30.0] 

Tine,  lavand.  comp oij  [8.0] 

Tine,  opii 3j  [4.0] 

Muc.  acaciae §ss  [15.0] 

Aquae  q.s.  ad giv  [120.0] 

S.     3j — 3ij  t.  i.  d.  3  to  4  times  a  day. 

^  Potassii  citratis 3ij  [8.0] 

Potassii  bromidi 3ij  [8.0] 

Liquor  potassii  hydroxidi 3i  [4.0] 

Ext.  hyoscyami  fl 3i  [4.0] 

Ext.  tritici  fl 3vi  [24.0] 

Aquae,  q.s.  ad §vi  [180.0] 

Sig.     Tablespoonful  three  or  four  times  a  day  in,  or  fol- 
lowed by,  half  a  glass  of  water. 

9  Hexamethylenaminae gr.  v  [0.3] 

Sodii  benzoatis gr.  x  [0.6] 

M.f.  pulv No.  i 

Tales  doses No.  xij   

S.     One  powder  in  a  glass  of  water  three  to  four  times  a 
day. 

^  Hexamethylenaminae gr.  vij  ss  [0.5] 

Sodii  (mono)  acidi  phosphatis gr.  xv  [1.0] 

M.f.  tabella  No.  i 

Tales  doses No.  xxx  

S.     One  in  a  glass  of  water  three  to  four  times  a  day. 


FORMULARY  293 

^  Methyllthioninae  hydrochlor gi*.  ij  [0.12] 

Phenyl  salicylatis gr.  iij  [0.18] 

Extr.  belladonnae gi".  %  [0.01] 

Pulv.  cinnamomi gr.  ss  [0.03] 

M.f.  capsula No.  i 

Tales  doses No.  xxx  

S.     One  capsule  three  to  four  times  a  day. 

1^  j\Iethylthioninae  hydrochl.    (methylene  blue) 

3i  [4.0] 

Phenyl  salicyl.  (salol)   3iij  [12.0] 

01.  santali 3v  [20.0] 

Oleores.  cubebae 3v  [20.0] 

Pancreatini oi  [4.0] 

01.  cinnamomi gr.  vi  [0.3] 

Div.  in  caps,  gelat.  no.  Ix. 
One  or  two  capsules  two  hours  after  each  meal. 

I.      FORMULAS  OF  CLEANSING  INJECTIONS 

J^  Sodii  bicarbonatis gr.  cl  [10.0] 

Aquae  destill.  steriliz Oj  [500.0] 

Mix  with  equal  volume  of  hot  water  and  inject  two  or 
three  syringefuls  every  hour  or  two.  (If  you  cannot  do  it 
so  often,  do  it  as  often  as  you  can.) 

1^  Sodii  boratis gr.  cl  [10.0] 

Aquae  destill.  steriliz Oj  [500.0] 

Directions  same  as  with  injection  No.  1. 

I^  Sodii  chloridi  c.  p gr.  xxx  [2.0] 

Aquae  destill.  steriliz Oij  [1000.0] 

Directions  same  as  with  No.  1. 


294      GONORRHEA  AND  ITS  COMPLICATIONS 

II.      FORMULAS  FOR  GONOCIDE  SOLUTIONS 

^  Protar^ol gr.  viij  [0.5] 

Aquae  destill gvijss  [200.0] 

M.  ft.  solutio  lege  artis.     Detur  in  vitro  nigro. 
Sig.     Use  one  syringeful  at  a  time  (two  to  four  drams, 
depending  on  the  capacity  of  the  man's  anterior  urethra), 
and  hold  in  five  to  ten  minutes. 

You  must  be  sure  that  the  solution  of  protargol  is  prop- 
erly prepared.  Improperly  prepared  it  contains  lumps  and 
will  prove  irritating.  The  best  way  to  make  a  solution  of 
protargol  is  to  pour  the  water  into  a  wide  graduate  or  a 
mortar,  and  then  throw,  with  a  sifting  motion,  the  protargol 
on  the  water ;  it  is  light  and  floats.  Leave  it  without  shaking 
or  stirring;  in  a  few  minutes  it  will  be  found  to  have  be- 
came dissolved.  As  seen,  I  commence  with  a  14  V^^  cent, 
solution  (1 :400) .  The  amount  may  be  raised  to  one  or  two 
per  cent.,  but  I  seldom  go  beyond  one  per  cent. 

Protargol  should  not  be  prescribed  with  zinc  sulphate :  the 
two  are  incompatible. 

^  Argyrol Sijss— 3v— Sxijss  [10.0—20.0—50.0] 

Aquae  destill gviij  [240.0] 

Use  the  same  way  as  the  protargol  solution. 

^  Protargol gr.  viii  [0.5] 

Argyrol Sijss  [10.0] 

Aquae  destill gvij  [200.0] 

Sig.     Use  one  syringeful  3  to  4  times  a  day. 

The  combination  of  the  two  silver  salts,  original  with  the 
author,  often  gives  very  happy  results.    Argyrol  alone  is 


FORMULARY  295 

often  too  mild  and  inefficient,  protargol  is  sometimes  too 
irritating,  but  the  combination  is  both  efficient  and  sooth- 
ing. I  could  find  no  incompatibility  between  the  two  chem- 
icals. 

^  Thalline  sulph gr.  xv  [1.0] 

Aquae  destill gvij  [200.0] 

This  is  a  %  per  cent,  solution ;  the  strength  may  be  raised 
to  2  per  cent.,  but  1  per  cent,  is  generally  the  most  satisfac- 
tory. 

^  Ichthyol 5i— 3jss  [4.0  to  6.0] 

Aquae  destill gviij   [240.0] 

This  is  used  in  *' dragging"  cases  and  is  good  as  an  al- 
ternate injection. 

m.      FORMULAS  FOR  ASTRINGENT   INJECTIONS 

^  Zinci  sulphatis gr.  viij  [0.5] 

Aquae  destill giv  [120.0] 

Inject  three  or  four  times  a  day. 

'^i  Zinci  sulphatis gr.  viij  [0.5] 

Plumbi  acetatis gr.  viij  [0.5] 

Aquae  destill giv  [120.0] 

Shake  well.     Inject  three  or  four  times  a  day. 

^  Zinci  sulphocarbolatis gr.  xvj  [1.0] 

Aquae  destill giv  [120.0] 

]^  Zinci  sulphatis. 

Plumbi  acetatis, aa  gr.  viij  [0.5] 

Tr.  opii , 5j  [4.0] 


296      GONORRHEA  AND  ITS  COMPLICATIONS 

Tr.  catechu 3ij  [8.0] 

Aquae  ad §iv  [120.0] 

The  following,  however,  is  my  favorite : 

1^  Zinci  sulphatis gr.  viij  [0.5] 

Bismuthi  subcarbon  (vel.  subnitr.)   ...   3iij  [12.0] 

Bismuthi  subgall 5j  [4.0] 

Hydrastis  aquos o3  [30.0] 

Pulv.  acaciae, ojss  [6.0] 

Aquae  ad giv  [120.0] 

M.  f.  mistura  lege  artis. 

Keep  bottle  flat  and  shake  well  before  using. 

[If  prepared  by  a  competent  pharmacist  this  prescription 
makes  a  smooth  homogeneous  mixture,  like  an  emulsion. 
Prepared  by  an  incompetent  pharmacist,  it  is  lumpy,  gritty, 
and  often  proves  irritating  to  the  urethra.] 

This  leaves  a  protecting  coating  over  the  urethral  canal, 
exerting  a  soothing  and  healing  influence.  The  coating  re- 
mains in  the  urethra  until  the  next  urination.  This  in- 
jection finishes  up  the  treatment. 

Ultzmann's  Injection: 

Zinci  sulphatis gr.  viij  [0.5] 

Aluminis gr.  viij  [0.5] 

Ac.  carbolici gr.  iv  [0.25] 

Aquae  giv  [120.0] 

Injection  in  non-gonorrheal  urethritis: 

^  Ac.  carbolici  (phenol) gr.  xij  [0.8] 

Zinci  sulphatis gr.  xx  [1.3] 

Aluminis gr.  xxx  [2.0] 

Aquae gviij  [250.0] 


FORMULARY  297 

S.  Inject  3  to  4  times  a  day,  holding  in  the  injection  3 
to  5  minutes. 

Europhen 5i  [4.0] 

01.  amygd.  express §j  [30.0] 

S.  gtt.  V-X  in  the  posterior  urethra,  in  chronic  posterior 
urethritis  and  prostatitis. 

Thymol  iodide 5i  [4.0] 

01.  amygd.  express §j  [30.0] 

S.  Use  same  as  previous  prescription.  Both  prescrip- 
tions may  be  made  a  little  weaker,  using  1  part  of  the  drug 
in  10  parts  of  almond  oil  or  olive  oil. 

Europhen 3ss  [2.0] 

Thymol  iodide Sss  [2.0] 

Vaselini  liquidi  albi 3x  [40.0] 

S.     gtt.  V-X  in  the  posterior  urethra  daily  or  every  other 

day,  in  obstinate  chronic  posterior  and  anterior  urethritis. 

Useful  also  after  dilatation  of  strictures,  as  it  probably  helps 

somewhat  in  their  absorption. 

^  Zinci  sulphatis gr.  xv  [1.0] 

Plumbi  acetatis gr.  xv  [1.0] 

Extr.  krameriae  fl. 5iij   [12.0] 

Tine,  opii 3ij  [8.0] 

Aquae  destill.  q.s.  ad §vi  [180.0] 

S.  Inject  3  to  4  times  a  day.  An  old  fashioned  prescrip- 
tion, but  quite  useful  in  gleet. 

'^i  Zinci  permanganatis  gr.  iij 

Aquae  destill ^'^i 

S.     Inject  3  to  6  times  daily. 


298      GONORRHEA  AND  ITS  COMPLICATIONS 

FOR  BALANITIS: 

^  Zinci  oxidi 5i  [4.0] 

Bism.  subnitratis 5i  [4.0] 

Ac.  salicylic! gr.  v  [0.3] 

Petrolati  albi §j  [30.0] 

^  Perhydrol  (100  vol.  Hydrogen  dioxide),  §j  [30.0] 
S.     Touch  up   any  erosions  with  a  small  cotton  swab 
dipped  in  perhydrol  and  then  wash  with  ordinary  hydrogen 
dioxide.     (In  erosive  balanitis.) 

FOR  ADENITIS   OR   BUBO: 

^  Ung.  hydrargyri 5ij   [8.0] 

Guaiacoli 5i  [4.0] 

Ung.  belladonnae §i  [30.0] 

^  Plumbi  lodidi 3i  [4.0] 

Ung.  Potassii  lodidi §i  [30.0] 

1^  Ung.  hydrargyri 5ij  [8.0] 

Guaiacol 5ss  [2.0] 

Adipis 3vi  [24.0] 

M.  ft.  unguentum   

Sig.    Apply  three  times  a  day  covering  with  gauze. 

ACUTE   PROSTATITIS 

^  Morphinae  sulphatis gr.  %  [0.02] 

Ext.  belladonnae gr.  %  [0.02] 

01.  theobromae gr.  xx  [1.3] 

For  one  suppository.     Tal.  dos.  xij. 
S.     One  3  times  a  day. 


FORMULARY  299 

:9  lodoformi gr.  ij  [0.12] 

Antipyrini gr.  v  [0.3] 

Morphinae  sulphatis gi*-  %  [0.015] 

01.  theobromae gr.  xxv  [1.5] 

Sig.     One  3  times  a  day. 

CHRONIC   PROSTATITIS 

5  lodoformi gr.  i  [0.06] 

Morph.  siilph gr.  %  [0.015] 

01.  theobromffi gr.  xxv  [1.5] 

M.f.  supp.  No.  1.     Tal.  dos.  xij. 
Sig.     One  t.  i.  d. 

^  Potassii  iodidi gr.  ij  [0.12] 

lodi  puri gr.  %  [0.015] 

Morph.  sulph gr.  %  [0.01] 

01.  theobromae gr.  xxx  [2.0] 

IJ  Ichthyol gr.  ij  [0.12] 

Potassii  iodidi  gr.  iij   [0.18] 

Morph.  sulph gr.  %  [0.015] 

01.  theobromae gr.  xxx  [2.0] 

^  Bism.  iodo-resorcin-sulphonatis gr.  ij   [0.12] 

Zinci  oxidi gr.  v  [0!32] 

01.  theobromae xxv  [1.5] 

^  Antipyrini gr.  v  [0.32] 

Sodii  iodidi gr.  iij  [0.18] 

01.  theobromae  . , gr.  xxx  [2.0] 

^  Morph.  sulph gr,  %  [0.015] 

Ext.  belladonnge gr.  %  [0.01] 

01.  theobromae gr.  xxx  [2.0] 


300      GONORRHEA  AND  ITS  COMPLICATIONS 

EPIDIDYMITIS 

Apply  large  gauze  compresses  wrung  out  of  a  hot  solution 
of  aluminum  acetate  containing  some  glycerin : 

^  Liquoris  alumini  acetatis, 

Glycerini aa  gviii  [250.0] 

Aquae   Oj    [500.0] 

M.  ft.  mistura. 

The  compress  is  to  be  covered  with  oil  silk  and,  if  the  pa- 
tient must  be  up  and  about,  the  whole  put  into  a  well  fitting 
suspensory  bandage.  The  compress  should  be  wrung  out  of 
the  hot  solution  every  hour. 

A  good  ointment  properly  applied  is  also  very  beneficial. 
My  favorite  formula  is : 
^  Unguenti  hydrargyri Sii  [8.0] 

Guaiacolis 1 

L...  aaSj  [4.0] 
Ichthyolis J 

Unguenti  belladonnae §ss  [15.0] 

Adipis  benzoinati,  q.s.  ad §ii  [60.0] 

M.     Sig. :     Apply  externally  twice  or  three  times  a  day. 

15  Hydrargyri  ammoniati 5ss  [2.0] 

Methylis  salicylatis 5j  [4.0] 

Morphinae  sulphatis gr.  iv  [0.25] 

Atropinae  sulphatis gr.  j  [0.06] 

Adipis  lanse §ss  [15.0] 

Adipis  benzoinati §j  [30.0] 

M.  ft.  ung. 


FORMULARY  301 

SUPPOSITORIES  FOR  GONORRHEAL  PROCTITIS 

^  Protargol gr.  i  [0.06] 

01.  theobromae gr.  xx  [1.3] 

M.f.  suppos.  No.  1.    Tal.  dos.  No.  xxx 
Sig.  one  t.  i.  d. 

^  Argyrol gr.  v  [0.3] 

01.  theobromae gr.  xxv  [1.5] 

M.f.  suppos.  No.  1.     Tal.  dos.  No.  xxx 

Sig.  one  t.  i.  d. 

These  may  be  used  twice  or  three  times  a  day. 

GONORRHEAL    ARTHRITIS 

Rub  the  painful  parts  with  an  ointment  consisting  of 
methyl  salicylate,  lard  and  woolf at : 

^  Methyl  salicylatis 3ij  [8.0] 

Adipis 3iv  [16.0] 

Adipis  lanae 3iv  [16.0] 

This  is  well  rubbed  in,  covered  with  non-absorbent  cotton 
and  oiled  silk  or  rubber  tissue.  The  whole  is  held  in  place 
by  a  well  fitting  gauze  or  rubber  bandage. 

Instead  of  the  ointment  I  often  have  the  joints  and  pain- 
ful parts  painted  with  the  following  mixture : 

^  Acidi  salicylici 3j   [4.0] 

Menthol gr.  xv  [1.0] 

Guaiacol gr.  xxx  [2.0] 

Alcohol §i  [30.0] 

The  joint  is  painted,  then  protected  with  non-absorbent 


302      GONORRHEA  AND  ITS  COMPLICATIONS 

cotton,  oiled  silk  and  rubber  tissue  the  same  as  after  the  use 
of  the  ointment. 

GONORRHEA  IN  WOMEN 

^  Aluminis §iv  [120.0] 

Zinci  sulphatis gi  [30.0] 

Cupri  sulphatis 5iv  [15.0] 

Sig.     Tablespoonful  to  1  or  2  quarts  of  water. 

5  Protargol gr .  v  [0.3] 

Olei  theobromae 3i  [4.0] 

M.  ft.  suppos.  ovale  vel  glob.  No.  I. 
D.  tal  dos.  No.  xij. 
Sig.    One  at  night ;  inserted  high  up  in  the  vagina. 

VULVO-VAGINITIS  IN  LITTLE  GIRLS 

^  Protargol gr.  ss  [0.03] 

Acidi  borici gr.  v  [0.32] 

01.  theobromae gr.  xxv  [1.5] 

M.  f.  suppos.  No.  1.    Tal.  dos.  No.  xxx 
Sig.     One  suppository  at  night. 

CHANCROIDAL  URETHRITIS 

^  Iodoform! gr.  ij  [0.12] 

01.  theobromae  gr.  xij   [0.8] 

M.  f.  suppos.  No.  1.    Tal.  dos.  No.  xij. 
Sig.     One  t.  i.  d. 

SYPHILITIC  OR  CHANCRE   URETHRITIS 

^5  Unguenti  hydrargyri gr.  i  [0.06] 

01.  theobromae gr.  x  [0.6] 


FORMULARY  303 

M.  f.  suppos.  urethral.  No.  1.    Tal.  dos.  xxx 
Sig.     One  bis  vel  ter  in  die. 

Instead  of  using  cacao  butter  alone  as  a  base,  the  phar- 
macist may  be  instructed  to  add  two  or  three  grains  of 
yellow  wax  to  each  suppository,  so  that  the  prescription 
would  read : 

F^  Unguenti  hydrargyri gr.  j  [0.06] 

Cerae  flavae gr.  ij  [0.12] 

01.  theobromae gr.  x  [0.6] 

M.  f.  suppos.  urethr.  No.  1. 

FOR   CONDYLOMATA 

^  Resorcinol, 

Hydrarg.  chlor,  mitis aa  3ij  [8.0] 

M.  ft.  pulvis  subtilis 
Sig.     Apply  externally. 

FOR   THE  PREVENTION   OF   GONORRHEA 

^  Calomel 50  gm. 

Liquid  petrolatum 80  c.c. 

Adeps  lanae 70  gm. 

Inject  a  few  drops  into  the  fossa  navicularis,  and  rub 
some  of  it  on  the  glans  and  sulcus. 

LUBRICANTS 

^  Mercury  oxycyanide  0,246 

Tragacanth  3.0 

Glycerin 20.0 

Aquae  destill.  steril 100.0 

(Casper) 


304      GONORRHEA  AND  ITS  COMPLICATIONS 

Some  hypersensitive  urethras  feel  some  irritation  from 
the  nse  of  this  lubricant.  It  is  also  a  little  too  thick,  par- 
ticularly in  cold  weather.  I  have  therefore  modified  the 
formula,  and  this  yields  me  a  more  satisfactory  product. 
My  modified  formula  is  as  follows : 

^  Mercury  oxy cyanide 0.2  [3  grains] 

Tragacanth 2.0  [30  gi'ains] 

Glycerin 20.0  [5  drams] 

Aquae  destill.  steriliz 120.0  [4.  ozs.] 

Keep  well  covered  in  small,  wide  mouthed  bottles,  or  have 
it  filled  in  tin  tubes. 

^  Ac.  salicylici gr.  x  [0.6] 

Olei  olivae giv  [120.0] 

Heat  on  a  water  bath  to  100°  C.  for  fifteen  minutes,  dis- 
solve the  salicylic  acid,  cool,  strain,  heat  again  for  five 
minutes  and  pour  in  sterilized  bottle  or  container. 

In  "dragging"  gonorrhea  and  in  gonorrheal  and  post- 
gonorrheal  neuroses: 

IJ  Elix.  ferri,  quinin.  et  strych.  phosphat.,  §vj  [180.0] 
S.     3i  3  times  a  day,  in  a  little  water,  before  or  after 
meals. 

^  Syrupi  hypophosphit.  compos §vi  [180.0] 

S.    3i  3  times  a  day,  in  a  little  water,  after  meals. 

The  above  two  prescriptions  may  look  rather  strange  in 
a  book  on  gonorrhea,  but  I  have  placed  them  here  purposely 
to  impress  on  the  physician's  mind  the  importance  of  pay- 


FOEMULARY  305 

ing  attention  to  the  patient's  general  health  while  treating 
his  gonorrhea.  Many  physicians  are  apt  to  forget  when 
treating  a  certain  definite  condition  (like  gonorrhea  or 
syphilis)  that  the  patient's  general  condition  is  also  of  im- 
portance. On  some  people  their  gonorrhea  produces  a  very 
depressing  effect.  It  is  possible  that  the  gonotoxin  causes 
anemia,  but  besides  this  the  depressing  effect  of  worry  about 
their  disease  interferes  with  their  appetite,  and  they  often 
run  down  and  lose  flesh,  etc.  In  such  conditions  it  is  just 
as  important,  perhaps  more  so,  to  give  the  patient  tonics  as 
it  is  to  give  him  sandalwood  internally  and  injections  locally. 
In  fact  the  patient's  gonorrhea  will  often  show  decided  im- 
provement if  we  stop  all  kinds  of  anti-gonorrheal  treatment 
for  awhile  and  just  give  him  tonics,  such  as  the  compound 
syrup  of  hypophosphites,  elixir  of  iron,  quinine  and  strych- 
nine, the  compound  glycerophosphates,  malt,  malt  and  cod 
liver  oil,  etc.  And  where  the  patient  develops  a  condition 
of  neurasthenia,  then  the  neurasthenia  must  be  treated  at  the 
same  time,  and  just  as  thoroughly  as  his  gonorrhea  is. 

[For  the  treatment  of  Neurasthenia  see  the  author's 
''Treatment  of  Sexual  Impotence  and  Other  Sexual  Dis- 
orders in  Men  and  "Women."] 

URETHRAL   SUPPOSITORIES  AND   BOUGIES 

As  -^ill  be  noticed,  I  have  not  recommended  any  bougies 
or  urethral  suppositories  for  gonorrheal  urethritis.  Dozens 
of  times  I  have  given  them  a  trial  and  each  and  every  time 
I  have  been  disappointed.  It  seems  so  plausible  that 
bougies  which  remain  in  the  urethra  for  many  minutes  or 
hours  at  a  time  should  exert  a  much  better  effect  than  in- 
jections, which  are  immediately  thrown  out  or  remain  in 


306      GONORRHEA  AND  ITS  COMPLICATIONS 

the  urethra  only  a  few  minutes  at  most.  But  unfortunately 
practice  does  not  always  corroborate  theories.  Theoretically 
bougies  ought  to  be  efficient,  more  efficient  than  injections, 
but  practically  they  are  not. 

Whether  it  is  due  to  the  fact  that  they  act  as  an  irritant 
or  whether  the  vehicle  (be  it  cocoa  butter  or  glycerin- 
gelatin)  prevents  the  action  of  the  chemical  agent  upon 
the  gonococci,  making  the  penetrating  power  even  much  less 
than  that  of  an  aqueous  solution,  the  fact  is  that  bougies 
have  in  my  hands  proved  much  less  efficient  than  injections, 
and  sometimes  they  have  even  proved  quite  irritating.  I 
have  therefore  discarded  them. 

Of  course  it  is  possible  that  some  new  vehicle  will  be  in- 
vented which  will  both  possess  penetrating  power  and  will 
permit  the  chemical  to  remain  in  contact  with  the  mucous 
membrane  for  a  long  time.  Should  such  a  vehicle  be  in- 
vented, then  I  will  give  the  suppositories  and  bougies  an- 
other trial.  Until  then  I  prefer  to  continue  with  aqueous 
solutions,  and  advise  others  to  do  the  same.  Still  if  one 
wishes  to  use  bougies,  P.  D.  and  Co.'s  Nargol  bougies  are 
as  good  as  any. 

An  agreeable  and  efficient  method  seems  to  be  the  incor- 
poration of  the  silver  salts,  etc.,  in  a  chondrus  jelly  vehicle. 
I  have  given  such  preparations  [Tuboblenal,  etc.]  a  mod- 
erate trial,  but  unfortunately  they  are  not  manufactured 
in  this  country;  and  it  is  questionable  whether  they  would 
in  the  long  run  prove  so  very  much  superior  to  aqueous  solu- 
tions. 

URETHRAL  DRAINS.  The  Same  objections  that  I  have 
against  bougies,  I  have,  but  in  a  still  greater  measure, 
against  urethral  drains.     The  pus  that  lies  superficially  on 


FORMULARY  307 

the  urethral  mucous  membrane  is  very  well  washed  away 
by  urination,  while  the  pus  and  gonocoeci  that  are  hid- 
den in  the  crypts  of  Morgagni  and  the  glands  of  Littre 
are  not  accessible  to  the  ''drains."  And  besides,  all 
theoretical  considerations  apart,  the  urethra  is  a  delicate 
tube  which  resents  all  foreign  bodies,  and  drains  are  apt  to 
cause  considerable  irritation. 


INDEX 


Abortive    treatment,    119-23 
Acute  prostatitis,  146-53 
Adami,    on    vaccines,    107 
Adenitis,    139 
Adrenalin,    145 
Agar-agar,  27 
Albargin,    51,   261 
Alcohol,   37 

injections,  78 

in  chronic  gonorrhea,  97,  209 
Allosan,   279 
Alum,  269 
Aluminium  acetate,  57,  76 

in   epididymitis,    174 
Alypin,    145,    197,    274 
Aminoform,   284 
Amphotropin,   284 
Antipyretics,  150 
Arbutin,  57,  76 
Argentamin,  261 
Argentol,  50 
Argentose,  50 
Argonin,  50-1,  262 
Argyrol,   50-51,    121,    129,   262 

deterioration  of,  253 

in  gonorrheal  ophthalmia,  247 
Arheol,  43,  279 
Arhovin,  282 
Aristol,  84 
Arsenic     iodide,     in     gonorrheal 

arthritis,    206 
Arthritis,   gonorrheal,   202-08 

differential  diagnosis  of,  203-4 

treatment  of,  204-8 
Asch,  176 


Aspirin,     in     acute     prostatitis, 
150 

in   epididymitis,   99,    177 
Atony  of  the  prostate,    166 
Atropine,  143 
Atropine  sulphate,  42,  57 

in  gonorrheal  ophthalmia,  247 
Auto-infection,    62 

Bacillus    bulgaricus,    in    female 

gonorrhea,  228 
Balanitis,   138 
Balsamics,   41,   42,   277 
Bazy,  256 
Beer,    urethral    discharge    from, 

89 
Belfield,    185 
Beta-eucaine,  275 
Bichloride,   urethritis  from,   75 
Bier's  hyperemia,   in  gonorrheal 

arthritis,  206 
Bismarck  brown,  23 
Blaschko,    127,   261 
Blenal,  279 
Borax,  47,  48 
Boric   acid,   47 

in  gonorrheal  ophthalmia,  246 
Borovertin,  285 
Bougies,  72,  305 
Bromides,   143 
Bubo,  139 
Buller's  shield,  246 
Burrow's  solution,   76,   135,   140 


Calomel  ointment,  130 


309 


310 


INDEX 


Calcium  sulphide,  in  gonorrheal 

arthritis,  206 
Carbosant,   279 
Cargentos,   262 

Caruncle,  urethral,  in  women,  251 
Casper,  120,  268,  289 
Catechu,  273 

Catheters,     precautions     regard- 
ing, 253 
Chancroidal    urethritis,    65 
Change  of  air,  in  chronic  gonor- 
rhea, 98 
Chemical  urethritis,  74 
Chetwood,   179 

Chinosol,  64,  66,   135,  138,  267 
Chondrus,  289 
Chordee,   32,   57,    141 
Chronic    gonorrhea,    nature    of, 
93-6 

case  reports,   93-6 

treatment  of,  97-108 

internal  treatment  of,  98 

length    of    time    required    to 
cure,    109 
Chronic  prostatitis,   154-67 
Circumcision,   126,  136 
Cocaine   hydrochloride,    274 
Coffee,  37 
Collargol,  263 

in  epididymitis,  176 
Colloidal  silver,  263 
Colloidal  silver  oxide,  262 
Colon  bacillus,  28 
Complement   fixation    test,    28 
Condom,  127 
Condylomata   acuminata,    231 

in  pregnancy,  233 
Constipation,  38 

in  chronic  gonorrhea,  98 

in    epididymitis,    177 
Conjunctivitis,  metastatic  gonor- 
rheal, 247 
Copaiba,   42,   280-1 

eruptions  from,  250 


Copper   sulphate,    102,   269 
Cowperitis,   141 
Crede,  245 
Cubebs,  42,  281 

eruptions  from,  250 
Cultures,  27,  252 
Curability    of    gonorrhea,    15 
Cure  of  gonorrhea,   testing   for, 
79 

cessation     of     discharge     not 
proof  of,  82 
Curettage,  in  female-  gonorrhea, 

223,  230 
Cystitis,  251 

from   stricture,    195 

hexamethylenamine    in,    283 
Cystogen,  285 

Diathesic  urethritis,  90 
Diet,  in  chronic  prostatitis,  158 
Dilators,    103,    105,   198 
Discharge,      cessation      of      not 
proof  of  cure,  82 
cessation  of  during  epididymi- 
tis, 171 
recurrent,   from  patches,   253 
Drains,  urethral,  306 

Electrargol,  in  epididymitis,  176 
Endocarditis,  250 
Endometritis,  229-30 
Endoscopic   applications,    101 
Enemas,   in   epididymitis,    177 
Epididymitis,  etiology  of,   168 

exercise  and,  98 

operative  treatment  of,   181 

recurrent,   99 

sequelae  of,  180 

sterility  from,   172,  182 

symptoms    and   course,    169-71 

treatment  of,    173-82 

urethral  treatment  in,  178 
Erb,   15 


INDEX 


311 


Erections,    imperfect,    157,    196 

painful,   141 
Ergot,  233 
Erythema,   250 
Eserine   sulphate,   in  gonorrheal 

ophthalmia,   247 
Eucaine,  275 
Europhen,    84 
Excess,  urethritis  from,  91 
Extravasation    of   urine,    195 
Extra- venereal    infection,    21-2 
Eyes,  danger  to,  38 

Faradization     of    the     prostate, 

167 
Feleki's  finger,  162 
Fistula,  urethral,   255 
Formin,  283 
Frequency     of     urination,     156, 

195 

in  women,  251-2 

Friecke,  179 

Fuchsin,  23 

Fuller,  185 

Gallic  acid,  273 
General  tonics,  305-6 
Glycerin,   as  a   lubricant,   289 
Glycerin-gelatin,  27 
Gonosan,  43,  279 
Gonococcus,   23 

Gonorrhea,     abortive     treatment 
of,  119 

alcohol  and,   37,   209 

complications    of,    rarer,   250 

constipation  and,  38 

curability    of,    15,    105,    113 

diet  in,  37 

etymology  of,  20 

general  measures  in,   36 

history  of,  20 

incubation  stage  of,  29 

of  mouth,  189 

of  nose,  190 


of  rectum,   187-8 

prevalence  of,  15 

prevention  of,   124,  216 

sexual  intercourse  during,  37, 
209 

social-economic  conditions  and, 
16,   36,   60,    105,   114,   173 

tobacco  during,  209 
Gonorrhea  in  women,   218-32 

coitus  during,   224 

curettage  in,  223,  230 

diet  in,  225 

incubation  of,  220-1 

pregnancy  and,  232-3 

prevention  of,  216 

symptoms  of,  221 

treatment  of,  222-32 

vaccines  in,  230 
Gonorrheal  conjunctivitis,  247 
Gonorrheal  ophthalmia,   243-9 

blindness  from,  244 

etiology  of,  243 

prophylaxis    of,    244 

symptoms  of,  245 

treatment  of,  246-7 
Gram  stain,  25,  26,  255 
Guiard,   129 
Guy  on   syringe,    100,    101 

Hamonic,  176 

Hegonon,   263 

Helmitol,    285 

Hemospermia,    183 

Hexal,  285 

Hexalet,  285 

Hexamethylenamine,      44,      198, 

283 
Hot  baths,  38,  144 

in  female  gonorrhea,  230 
Hydrastis,   95,  273 
Hydrastin,   273 
Hydrastinine,    273 
Hydrogen  peroxide,  49,  50 
Hyoscyamus,   42,    144 


312 


INDEX 


Ichthyol,  49,  50,  52,   102,  268 
suppositories  in  acute  prosta- 
titis, 151 

Icththargan,   51,   264 

Incubation    stage    of   gonorrhea, 
29 
in  women,  220-1 

Inguinal  adenitis,   139 

Injections,    in    acute   gonorrhea, 
45-54,  252,  253 
how  to  take,  117 
in  female  gonorrhea,  226-7 

Instillations,  83,   100 

Instructions  to  patients,  38-9 

Internal  treatment,  256 

Iodine    injections    and    applica- 
tions,  102 
in  stricture,  199 
in  female  gonorrhea,  226,  229 
in  venereal  warts,  232 
in  vulvo-vaginitis,  240 

Iodine    derivatives,    in    chemical 
urethritis,  84 

Iodoform,  66 

Irrigations,  8,   100 

Janet- Valentine    irrigator,    100 
Janet-Frank  syringe,  100,  118 

K-Y  jelly,  290 

Kaolin,    in    vulvo-vaginitis,    241 

Kava-kava,  43 

Kava-santal,  279 

Koller,    274 

Kollmann  dilators,   198 

Krameria,   273 

Lactic    acid,    in    female    gonor- 
rhea,  226 
in  venereal  warts,  231 
in   vulvo-vaginitis,    240 

Lactosantal,  43 

Lafayette  mixture,  281 

Largin,  51,  264 


Lassar,  79 

Lead  acetate,  270 

Leeches,  in  cowperitis,  140 

in  acute  prostatitis,   150 
Leucorrhea,    infection    from,    62 

gonorrhea  mistaken  for,  219 
Linseed,  76 
Loeflfler's    solution,    24 
Lubraseptic,   290 
Lubricants,  288 
Lubrichondrin,   290 
Lugol's    solution,    26 
Lupulin,   143 
Luys,   8 
Lymphangitis,    140 

Magnesium    sulphate,    in    acute 

prostatitis,   151 
in   epididymitis,    177 
Massage,  prostatic,   158-63 
of  seminal  vesicles,  185 
over  sounds,   104 
Masturbation,    urethritis    from, 

91 
Materia    medica    of    gonorrhea, 

258 
Matico,  273 
Meatotomy,   199-201 
Meatus,  narrow,  103,  155 
Menstruation,     infection     after, 

62 
urethritis      from      intercourse 

during,  253 
Mercurial  suppositories,  68,   151 
Mercuric   chloride,   49,   64,    129 
Mercuric   oxycyanide,    64,    269 
Metastatic    complications,    250 
Metastatic    gonorrheal    conjunc- 
tivitis, 247 
Metchnikoff,   130 
Methyl   violet,    23 
Methylene  blue,   23,   24,  25,   45, 

286 
Micrococcus  catarrhalis,   25 


INDEX 


313 


Monobromated   camphor,    143 
MoRosodic   acid   phosphate,   283- 

4-G 
Morning  drop,  9-4 
Morphine,  in  epididymitis,   177 
Morphine   suppositories,    57,    76, 

143,  150 
Mouth,  gonorrhea  of  the,   190 

Nargol,  51,  264 

bougies,  306 
Neisser,  20,  21 
Neoplastic    urethritis,    72 
Xicolle  and  Blaizot,   107 
Nizin,  272 

Nose,  gonorrhea  of  the,    190 
Novargan,  264 
Novocaine,  276 
Nutgall,    273 

Oakbark,   273 

Ober lander  dilators,  198 

Ointments       for       epididymitis, 

175-6 
Olive  oil,  in  chemical  urethritis, 

85 
Omorol,  265 

Ophthalmia    neonatorimi,    243 
not  ahvays  due  to  gonococcus, 

248 
Orchiepididymitis,   180 
Over -treatment,  256 

chronic   urethritis   from,    94 

Pain,   at   end  of   penis,   251 
Paraphimosis,    137 
Periurethritis,    140 
Penis  clamp,  117 
Penis,  pain  at  end  of,  251 
Phenacetin,    150 
Phimosis,  134 
Phosphates  in  urine,  251 
Phosphaturia,    157 


Picratol,  51,  265 

Pituitary    preparations,    233 

Pneumonia,     urethral     discharge 

during,    90 
Pollutions,  in  chronic  gonorrhea, 

214 
in  stricture,  196 
Post-gonorrheal  catarrh,  94 
Potassiiun  acetate,  76 
Potassiimi  citrate,  56 
Potassiimi    hydroxide,    42 
Potassium  nitrate,  90 
Potassiimi      permanganate,      49, 

58,  64,  129,  267 
Premature  ejaculation,  157,  166, 

183,   196,  201 
Prevalence  of  gonorrhea,  14 
Prevention    of   gonorrhea,    124 

in  women,  216 
Proctitis,    gonorrheal,    187-8 
Prophylactic    urethritis,    86 
Prostate,  atony  of  the,  166 
Prostatic  abscess,   152 
Prostatic  massage,   158-63 
Prostatic    psychrophores,    164 
Prostatitis,   acute,    146-53 

chronic,   154-67 
Prostatorrhea,   166 
Protargol,  50-1,  58,  59,  121,  129, 

265 
in  gonorrheal  proctitis,   188 
in  vulvo-vaginitis,  241 
in  gonorrheal  ophthalmia,  247 
Psychrophores,    prostatic,    164 

in  acute  prostatitis,  151 
Pyemia,  250 
Pyospermia,  183 
Pyramidon,  150 

Record  syringe,   118 

Rectal     injections,     in     chronic 

prostatitis,    165 
Rectum,   gonorrhea   of,    187-8 
Resorcin,  in  venereal  warts,  232 


314 


INDEX 


Resorcinol,   71 

Retention    of    urine,     144,     193, 

194 
Eheumatism,         gonorrheal — see 

Arthritis 
Ricord,  55,   147 
Roux,   25 

Saffronin,  23 

Salicylates,  in  epididymitis,   177 

in  gonorrheal  arthritis,  205 
Salicylic  acid,  135 

in    venereal    warts,    231-2 
Saliformin,  285 
Salol,  99 

Salpingitis,  220,  229-30 
Sandalwood  oil,   41,   42,   43,   58, 
99,  149,  277 

eruptions  from,  250 
Santyl,  43,  279 
Seminal  vesiculitis,    183-6 
Septicemia,  250 
Sexual    intercourse,    in    chronic 

gonorrhea,  98 
Shreds  in  urine,  194,  251 
Silberol,  51 
Silver  casein,  262 
Silver  fluoride,  50 
Silver  ichthyol,  264 
Silver    iodide,    50,    261 
Silver    gelatose,    261 
Silver  nitrate,  50,  64,  260,  272 

endoscopic      applications      of, 
101 

in  chronic  gonorrhea,  99 

in   female   gonorrhea,    228-9 

irrigations       and       injections, 
99-101 

in      ophthalmia     neonatorum, 
245 

in  vulvo-vaginitis,  240-1 

urethritis    from,    78,    83,    94, 
120 
Silver  proteid,  265 


Silver  proteinate,   264 

Silver    nucleid,    264 

Silver    salts,    254,    260-66 

Silver  vitellin,  262 

Silvol,  266 

Sinclair,  244 

Skin   eruptions,   250 

Smears,  how  to  prepare,  24 

Smoking,  38 

Sodium  acid  phosphate,  44,  286 

Sodium    benzoate,    44,    98 

Sodium   bicarbonate,   47,   48 

Sodium  chloride,  47,  48 

Sophol,  266 

in      ophthalmia     neonatorum, 
245,  247 
Sounds,   104,   196-8 

care  of,  254 

comparative  scale  of,  257 
Spongeitis,  140 
Stains,  23 
Staphylococcus,  28 
Sterility,  following  epididymitis, 
172,  182 

from  vulvo-vaginitis,  238' 
Stomatitis,    gonorrheal,    189 
Strangury,    31 
Stricture,   191-9 

symptoms  of,   193 

treatment  of,  196-9 

dilatation  of,  254 

of  bulbous  urethra,  256 
Suppositories,    in    female  gonor- 
rhea, 228 

for   acute   prostatitis,    151 

in  chronic   prostatitis,    165 
Syphilitic  urethritis,   67 
Syringes,   116,   118 

Tannic  acid,  273 

Testing  the  cure,  79 

Thalline  sulphate,  49,  50,  52,  268 

Thymol   iodide,    77,    78 

Thyresol,    43,    280 


INDEX 


315 


Tonics,  general,   305-6 
Toxic   urethritis,    89 
Tragacanth,  289 
Traumatic   urethritis,   88 
Triticum,  76 

Tubercular  urethritis,   72 
Tliberculosis    of    testicle,    181 
Tuboblenal,  306 

Typhoid,       urethral       discharge 
during,  90 

Ultzmann   syringe,    101 
Unguentum  Crede,  in  gonorrheal 

arthritis,  206 
Urethral  chill,  104 
Urethral   drains,    306 
Urethral   suppositories,   305 
Urethritis,    chancroidal,    65 

chemical,  74 

during    menstruation,    253 

during  pneumonia,   90 

during  typhoid,  90 

from  excess,  91 

from  intercourse  during  men- 
struation,  253 

from  overtreatment,   94 

from  silver  nitrate,  78,  83,  94, 
120 

neoplastic,  72 

post-gonorrheal,  94 

syphilitic,  67 

traumatic,  88 

toxic,  89 

tubercular,  72 
Urethroscopy,  8,  255 
Urination,  frequency  of,  156,  195 

frequency  of  in  women,  251-2 

how  to  induce,  251 


Urine,  cloudy,  251 
extravasation  of,   195 
phosphates  in,  157,  251 
retention    of,    144,    193,    194 
shreds  in,  194,  251 

Uritone,  283 

Urotropin,  44,  98,  283,  285 

Vacuum  treatment,  214 
Vaccines,  106-8 

in  gonorrheal  arthritis,  207 

in  salpingitis,  230 

in  vulvo-vaginitis,  242 
Vaughan,  on  vaccines,  108 
Venereal  warts,  71,  231-2 
Vesiculitis,   183-6 
Vesiculotomy,  185,  208 
Vulvo-vaginitis    in    little    girls, 
22,  234-42 

etiology  of,  234-6 

complications   of,   237 

hastens  sexual  maturity,  238 

prophylaxis  of,  239 

symptomatology,  236 

treatment  of,  239 

Wossidlo,  8 

Yeast,   in  vulvo-vaginitis,  241 

Zinc  acetate,  95,  271 

Zinc  chloride,   271 

Zinc  iodide,   271 

Zinc  permanganate,   272 

Zinc  sulphate,  53,  58,  77,   101-2, 

248,  271 

Zinc  sulphocarbolate,   53 


Consensus  of  Opinion :  The  Best  Book  of  Its  Kind  in  Any  Language 

There  is  no  class  of  disorders  with  which  the  physician  is 
so  Httle  famiKar  as  the  diseases  and  disorders  of  the  sexual 
function.  There  is  no  book  in  any  language  which  gives  such 
a  complete  practical  presentation  of  the  entire  subject  as 
does 

A  PRACTICAL  TREATISE  ON  THE 

CAUSES,  SYMPTOMS  and  TREATMENT  OF 

SEXUAL  IMPOTENCE 

AND  OTHER  SEXUAL  DISORDERS  IN  MEN  AND  WOMEN 
By  WILLIAM  J.  ROBINSON,  PH.G.,  M.D. 

Chief  of  the  Department  of-^Genlto-Urlnary  Diseases  and  Dermatology,  EBronx  Hospital  and  Dispensary: 
Editor  of  The  American  Journal  of  Urology  and  Sexology;  Editor  of  The  Critic  and  Guide;  Author  of 
Treatment  of  Sexual  Impotence  and  Other  Sexual  Disorders  In  Men  and  Women;  Treatment  of  Gonorrhea 
In  Men  and  Women;  Limitation  of  Offspring  by  the  Prevention  of  Conception;  Sex  Knowledge  for  Girls  and 
Women;  Sexual  Problems  of  Today;  Never  Told  Tales;  Practical  Eugenics,  etc.  Fellow  of  the  New  York 
Academy  of  Medicine,  of  the  American  Medical  Editors'  Association,  American  Medical  Association,  New  York 
State  Medical  Society,  Internationale  Gesellschaft  fur  Sexualforschung,  American  Genetic  Association, 
American  Association  for  the  Advancement  of  Science,  American  Urologlcal  Association,  etc.,  etc. 

ILLUSTRATED 

We  know  of  no  book  about  which  the  opinions  of  the  med- 
ical press  are  so  unanimously  favorable.  Both  here  and 
abroad  it  is  considered  the  most  satisfactory  treatise  on  sexual 
disorders  in  men  and  women. 

BRIEF  SYNOPSIS  OF  CONTENTS. 

Part  I — Masturbation.  Its  Prevalence,  Causes,  Varieties,  Symptoms,  Results,  Prophy- 
laxis and  Treatment.    Coitus  Interruptus  and  Its  Effects.    12  chapters. 

Part  II — Varieties,  Causes  and  Treatment  of  Pollutions,  Spermatorrhea,  Prostatorrhea 
and  Urethrorrhea.     9  chapters. 

Part  III — Sexual  Impotence  in  the  Male.  Every  phase  of  its  widely  varying  Causes  and 
Treatment,  with  illuminating  Case  Reports.     9  chapters. 

Part  IV — Sexual  Neurasthenia.  Causes,  Treatment,  Case  Reports,  and  its  relation  to 
Impotence.     5  chapters. 

Part  V — Sterility,  Male  and  Female.    Its  Causes  and  Treatment.    6  chapters. 

Part  VI — Sexual  Disorders  in  Woman,  Including  Frigidity,  Vaginismus,  Adherent  Clitoris, 
and  Injuries  to  the  Female  in  Coitus.     4  chapters. 

Part  VII — Priapism.    Etiology,  Case  Reports  and  Treatment.    3  chapters. 

Part  VIII — Miscellaneous  Topics,  including:  Is  Masturbation  a  Vice? — Two  Kinds  of 
Premature  Ejaculation. — The  Frequency  of  Coitus. — "  Useless  "  Sexual  Excitement. — The 
Relation  Between  Mental  and  Sexual  Activity.— Big  Families  and  Sexual  Vigor. — Sexual 
Perversions.     9  chapters. 

Part  IX — Prescriptions  and  Minor  Points. 


Cloth  hound,  1^22  pages.     Postpaid,  $3.00 
THE  CRITIC  AND  GUIDE  CO.,  12  Mt.  Morris  Park  W.,  New  York  City 


SOME  COMMENTS  FROM  THE  MEDICAL  PRESS 


Medical  Fortnightly:  No  American  author- 
ity has  given  more  serious  thought  to  the 
subject  of  sexual  diseases  than  the  author  of 
this  volume;  he  has  given  to  us  in  it  the 
best  that  in  him  Kes.  No  physician  who 
has  had  to  combat  this  distressing  condition, 
and  those  conditions  dependent  upon  it,  has 
any  doubt  of  its  serious  importance.  And 
we  all  recognize  the  weakness  of  the  litera- 
ture on  the  subject.  Dr.  Robinson  takes  a 
sensible  view  of  things  which  have  not  been 
sensibly  considered;  nowhere  has  he  shown 
this  to  better  advantage  than  in  this  volume 
on  a  difficult  subject. 

Buffalo  Medical  Journal:  Dr.  Robinson 
discusses  the  numerous  phases  of  this  sub- 
ject, in  both  sexes,  clearly  and  in  detail.  If 
we  were  to  select  any  one  feature  of  this  work 
for  special  mention,  it  would  be  the  uniform 
common  sense  of  the  author. 

Indianapolis  Medical  Journal:  This  book 
is  not  by  any  means  a  rehash  of  some  other 
book  or  a  resume  of  several.  This  treatise 
is  interesting  and  valuable,  and  the  author 
is  absolutely  honest  and  fearless  in  his  opin- 
ions. A  unique  and  helpful  feature  is  the 
case  reports  which  illustrate  every  phase  of 
sexual  disorder. 

Texas  State  Journal  of  Medicine:  Dr. 
Robinson  deals  with  the  subject  in  a  digni- 
fied, scientific  way,  that  w^U  be  helpful  to 
the  physician.  This  book  will  do  much  good, 
and  that  good  will  be  as  extensive  as  its 
circulation. 

Charlotte  Medical  Journal:  In  this  book 
we  have  a  complete  treatise  on  sexual  dis- 
orders and  their  treatment,  with  descrip- 
tions of  actual  individual  cases,  giving  the 
individual  s\Tnptomatology  and  individual 
treatment.  When  given  in  this  manner  the 
description  becomes  indelibly  impressed  on 
the  memory  and  enables  a  physician  when 
he  gets  a  case  to  understand  and  classify  it 
without  a  great  amount  of  difficulty. 

Southern  California  Practitioner:  The 
name  of  the  author  is  ample  assurance  that 
this  treatise  is  not  a  rehash  nor  lacking  in 
honest  opinions  fearlessly  expressed.  The 
style  of  the  writer  is  notably  personal,  clear, 
straightforward  and  conversational. 

Illinois  Medical  Journal:  Perhaps  no  sub- 
ject pertaining  to  human  ills  has  been  so 
neglected  by  medical  teachers  or  medical 
text-books  as  the  subject  discussed  in  this 
volume.    While  legitimate  medical  literature 


was  silent  on  sex  teachings,  the  quack  litera- 
ture was  teeming  with  misinformation,  which, 
as  the  author  intimates,  did  more  real  harm 
than  did  sexual  ignorance  or  sex  abuse.  The 
doctor  will  find  this  work  instructive. 

Medical  Times:  As  is  to  be  expected 
Robinson  goes  into  the  subject  thoroly,  and 
calls  a  spade  a  spade,  with  the  result  that 
he  has  evolved  a  volume  full  of  meat  and  of 
great  value  to  the  physician,  whose  ingenuity 
is  often  taxed  to  the  utmost  to  discover  the 
whys  and  wherefores  at  the  bottom  of  im- 
potence. ■ 

Therapeutic  Record:  Dr.  William  J.  Rob- 
inson is  to-day  the  most  eminent  student  of 
venereal  disease.  This  fact  will  not  need 
substantiation  by  those  who  have  followed 
his  work  as  set  forth  in  his  various  books. 
This  volume  is  a  complete  treatise  on  sexual 
impotence.  It  has  the  merit  of  being  a  prac- 
tical work.  By  this  we  mean  it  can  be 
readily  consulted  and  the  author's  meaning 
is  always  plain.  Dr.  Robinson  is  a  forceful 
writer  and  his  teachings  are  up-to-date.  No 
practitioner  can  afford  to  be  without  this 
book. 

Medical  Summary:  The  author  states  his 
views  on  certain  mooted  sexual  questions 
with  an  unequivocal  clearness  and  positive- 
ness  which  certainly  leaves  no  doubt  in  the 
reader's  mind  as  to  just  what  the  author 
wanted  to  say.  This  is  a  book  full  of  meat, 
served  up  in  the  author's  frank  style. 

Pacific  Medical  Journal:  We  make  unhes- 
itatingly the  statement  that  this  is  the  only 
complete  treatise  on  sexual  impotence  and 
other  sexual  disorders  in  the  English  or  any 
other  language.  Any  physician  who  has 
made  a  careful  study  of  the  book  cannot 
fail  to  treat  his  cases  with  a  fair  degree  of 
success.    It  is  a  distinctly  practical  volume. 

Denver  Medical  Times:  The  author  has 
departed  from  the  usual  technical  writing  of 
books.  "\^Tiile  his  views  may  appear  radical 
at  times,  his  style  is  interesting,  forceful, 
simple  and  yet  elegant.  The  work  is  the 
result  of  the  author's  experience,  of  which 
he  is  easily  the  literary  and  practical  master. 

Cincinnati  Lancet-Clinic:  Patients  suffer- 
ing from  sexual  disturbances  present  them- 
selves to  every  physician,  be  he  specialist  or 
general  practitioner.  For  this  reason  this 
book  by  Dr.  Robinson  appeals  to  the  entire 
medical  profession. 


A  Book  That   Every  Physician  Should  Possess 


Medical  Herald :  Dr.  Robinson  has  written 
a  great  deal  on  the  sex  question.  There  is 
a  large  fund  of  information  in  this  book 
!  which  should  be  known.  The  clinical  phases 
of  the  subject  have  been  kept  in  mind,  the 
frequent  reports  of  cases,  etc.,  fill  the  needs 
of  the  physician.  Impotence  is  reviewed 
from  every  practical  standpoint. 

American  Journal  of  Clinical  Medicine: 
Especially  interesting  are  the  chapters  upon 
treatment.  These  are  in  every  respect  ex- 
cellent and  practical  and  cannot  fail  to  be 
of  service  to  any  physician  who  has  patients 
of  this  kind  to  treat — and.  who  has  not.'' 

Northwest  Medicine :  The  author  expresses 
himself  and  his  original  ideas  with  the  well 
known  characteristic  freedom  which  has 
given  his  editorials  in  The  Critic  and  Guide 
such  wide  publicity  and  interest. 

Archives  of  Diagnosis:  Special  emphasis  is 
laid  on  treatment,  and  there  are  a  number  of 
entirely  new  conceptions  dwelt  upon.  It  is 
one  of  the  most  interesting  clinical  surveys 
of  the  subject  ever  offered  to  the  profession. 

Texas  Medical  Journal:  Dr.  Robinson,  the 
author  of  this  book,  is  a  specialist  of  national 
reputation  and  be  is  one  of  the  most  forcible 
writers  in  the  medical  profession.  Such 
works  as  the  one  before  us,  are  doing  a  great 
work  in  enlightening  the  medical  profession 
and  thru  them,  the  men  and  women  of  the 
country,  who  most  need  enlightenment,  ad- 
vice and  treatment,  upon  the  sex  question. 
It  is  certainly  a  valuable  book  to  the  profes- 
sion and  contains  information  of  inestimable 
importance.  The  successful  physician  of  the 
present  time  must  acquaint  himself  with  the 
far-reaching  influence  of  the  sex  question. 
Certainly  the  successful  management  of 
cases  of  sexual  impotence  by  the  family 
physician  will  build  up  for  him  a  reputation 
with  the  result  that  he  will  not  only  be  well- 
paid  financially  but  will  enjoy  the  lasting 
thanks  of  his  patients  as  well. 

The  Journal-Lancet:  The  author  wastes 
Qo  time  on  anatomy,  physiology,  and  various 
theories,  which  may  be  found  in  other  places, 
but  goes  directly  at  his  subject,  devoting  the 
most  space  to  those  things  which  are  of  the 
greatest  practical  importance,  namely:  mas- 
turbation, and  its  influence  on  sexual  dis- 
orders, pollutions  and  spermatorrhea,  sexual 
impotence,  sexual  neurasthenia,  and  sterility 
with  its  treatment.  The  ground  covered 
under  the  above  subjects  is  not  only  in- 
tensely interesting  but  immensely  important 
and  practical;  and  few  men  will  read  the  book 
without  some  benefit. 

Medical  World:  The  author  is  a  master 


of  his  subject  and  has  produced  a  work  of 
exceedingly  great  value.  It  will  be  appre- 
ciated by  all  medical  men  who  very  fre- 
quently meet  cases  included  in  this  category 
and  require  aid. 

Medical  Sentinel:  Dr.  Robinson  has  taken 
a  prominent  lead  in  modernizing  our  present 
day  sexual  viewpoint.  Many  who  write  on 
these  lines  are  theorists  and  dreamers,  but 
Robinson's  writings  stand  apart  by  their 
very  practicability.  Thruout  this  work  the 
needs  of  the  physician  have  been  kept  in 
mind,  and  the  result  is  a  sane,  sensible  and 
useful  book. 

Medical  Council:  Dr.  Robinson's  well- 
known  ability  in  the  clinical  field  of  sexual 
deviations  finds  practical  and  scientific  ex- 
pression in  this  book,  which  is  an  adequate 
guide  in  the  treatment  of  the  sexual  disorders 
of  both  men  and  women. 

American  Practitioner:  We  think  that  all 
readers  of  Dr.  Robinson's  book  will  be  es^ 
pecially  interested  in  his  treatment  of  ster- 
ility and  sexual  neurasthenia,  and  we  believe 
the  work  worthy  of  wide  circulation  among 
physicians. 

Chicago  Medical  Recorder:  The  author 
discusses  fully  and  freely  the  questions  of 
masturbation,  pollutions  and  spermatorrhea, 
sexual  impotence  in  the  male  and  sexual 
neurasthenia;  sterility  in  man  and  woman, 
certain  sexual  disorders  in  woman,  priapism, 
and  various  miscellaneous  topics.  A  for- 
mulary of  prescriptions  follov/ed  by  an  index 
conclude  the  volume.  It  is  a  pleasure  to 
recommend  this  very  interesting  work.  The 
sections  devoted  to  treatment  are  excellent. 
The  author  is  to  be  congratulated  upon  his 
manner  of  presentation.  He  expresses  his 
opinions  clearly  and  unmistakably. 

International  Journal  of  Surgery:  A  thoro 
perusal  of  this  book  con\Tlnces  one  that  the 
author  has  spent  much  time  in  the  study 
and  observation  of  cases  suffering  with  sexual 
disorders.  This  work  is  exceedingly  well 
written  and  to  the  point.  The  case  reports, 
typical  and  atypical,  are  numerous  and 
should  be  carefully  studied,  as  much  good 
material  is  presented  therein.  Dr.  Robin- 
son shows  that  he  is  a  past  master  in  his- 
tory taking,  which  is  a  very  important  part 
of  diagnostic  technique.  .  .  .  Sexual  disorders 
of  the  female  are  incorporated  in  this  book, 
which  increases  its  value,  as  these  conditions 
are  much  less  understood  than  those  occur- 
ring in  the  male.  This  book  should  appeal  to 
the  general  practitioner  especially,  for  it  is 
to  him  that  these  cases  make  their  first  ap- 
peal for  relief. 


Please  do  not  confuse  this  book  with  the  hodge-podge,  platitud 
nous  sex  books  which  flood  the  market.  This  is  a  Real  Boo 
and  it  tells  the  Truth. 

Woman:    Her  Sex 

Love  Life 

FOR  MEN  AND  WOMEN 

BY  WILLIAM  J.  ROBINSON,  M.D. 

ILLUSTRATED 

This  is  one  of  the  most  important,  most  useful  books  the 
we  have  ever  brought  out.  It  is  not  devoted  to  abstruse  dij 
cussions  or  doubtful  theories :  it  is  full  of  practical  inf ormatio 
of  vital  importance  to  every  woman  and  through  her  to  ever 
man,  to  every  wife  and  through  her  to  every  husband. 

The  simple  practical  points  contained  in  its  page*^  ^ul 
render  millions  of  homes  happier  abodes  than  they  oy\ 

they  would  prevent  the  disruption  of  many  a  fam  ehe 
show  how  to  hold  the  love  of  a  man,  how  to  preser^  ^xm 
attraction,  how  to  remain  young  beyond  the  usually  )tte 
age.  This  book  destroys  many  injurious  errors  an.  ^iupei 
stitions  and  teaches  truths  that  have  never  been  presente 
in  any  other  book  before.  In  short,  this  book  not  only  in 
parts  interesting  facts;  it  gives  practical  points  which  wi 
make  thousands  of  women,  and  thousands  of  men  happie 
healthier,  and  more  satisfied  with  life.  Certain  single  chaj 
ters  or  even  paragraphs  are  alone  worth  the  price  of  the  bool 

You  may  safely  order  the  book  without  delay.     But 
you  wish,  a  complete  synopsis  of  contents  will  be  sent  yoi 

Cloth  bound.     Price  $3.00 

THE   CRITIC  AND   GUIDE   CO.,    12  Mt.  Morris  Park  W.,  New  York  Cii 

Sex  Knowledge  for  Girls  and  Women 

Or  What  Every  Girl  and  Woman  Should  Know 

Illustrated 

Condensed  from  the  Author's  "Woman :  Her  Sex  and  Love  Life. 

Price  $1.00 
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